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/ Member Scheme Benefit Options / CompCare Wellness Medical Scheme / 2019 PAGE ACompCare Wellness Medical Scheme is administered by Universal Healthcare Administrators (Pty) Ltd
BENEFIT OPTIONS
2019
PREVENTATIVE CARE & WELLNESS BENEFITS PAID FROM RISK
EMOTIONAL WELLNESS
INFORMATION AT YOUR FINGERTIPS: DOWNLOAD OUR APP TODAY!
MEDICAL COVER FOR
With CompCare’sActive Lifestyle Programme
JUMPSTART YOUR BODY!
Exercise prescriptionHealthy eating
PLUSMen’s health
Women’s healthKids’ health
ADVENTURE SEEKERS
/ Member Scheme Benefit Options / CompCare Wellness Medical Scheme / 2019PAGE 1
5. BENEFITSView all your benefits, annual limits and your available balances.
6. MUCH MORERequest your Tax or Member Certificates. See all your registered Chronic Conditions, register new conditions, update your scripts and apply for an extended supply. Access your personal details, your dependant details and your Scheme details. You can also search for Network Specialists in your area.
1. CLAIMSSubmit new claims and view your claims history.
2. HOSPITAL PRE-AUTHORISATIONSubmit new pre-auth requests and view your hospital pre-auth history.
3. QUERYSubmit queries and view important contact details.
4. MEMBERSHIP CARDSee a digital version of your Membership Card and never be caught without it again.
Our Member App is your mobile gateway to information. Access and view your medical scheme option, benefits and claims anywhere, anytime.
Choosing the best medical scheme for you, your family or the employees of your company, is no small matter, as the choices made will have long-term consequences.
CompCare is a long-standing scheme with an outstanding track record of “being there when you need us most”. Not only is our offering among the most affordable, but the scheme has also been independently ranked as one of the most financially sustainable schemes on the market. And as you’d expect, CompCare does not only have rich benefits catering for every taste and need, but we are also known for highly innovative product design and some of the best preventative care and wellness benefit packages available anywhere.
We are also one of very few schemes covering professional and adventure sports.
Our committed and dedicated approach to member wellbeing ensures that individualised care is available to every member, with a “high touch” approach to care management.CompCare works very closely with our administrator, Universal Healthcare, to ensure our members have access to service excellence and evidence-based medicine using internationally benchmarked clinical protocols – but with a caring approach.
When it comes to your healthcare needs, we’ve got you covered.
Josua JoubertPrincipal Officer and CEOCompCare Wellness Medical Scheme
FROM THE PEN OF THE PRINCIPAL OFFICER
INFORMATION AT YOUR FINGERTIPS
/ Member Scheme Benefit Options / CompCare Wellness Medical Scheme / 2019 PAGE 2
PRODUCT OVERVIEW
The DYNAMIX option is a new generation option that offers complete cover with unlimited hospital cover and extensive day-to-day benefits. This option offers a savings account, flexible risk cover and ample above-threshold benefits.
The DYNAMIX ED option is a new generation option that offers complete cover, with unlimited hospital cover within the Netcare Group of private hospitals. The plan offers extensive day-to-day benefits. This option offers a savings account, flexible risk cover and ample above-threshold benefits.
DYNAMIX / DYNAMIX ED
The PINNACLE option is a new generation option that offers comprehensive cover, with unlimited hospital cover and superior day-to-day benefits. This option offers a savings account, flexible risk cover and extensive above-threshold benefits.
The PINNACLE ED option is a new generation option that offers comprehensive cover, with unlimited hospital cover within the Netcare Group of private hospitals. The plan offers superior day-to-day benefits. This option offers a savings account, flexible risk cover and extensive above-threshold benefits.
PINNACLE / PINNACLE ED
The SYMMETRY option is a new generation option that offers exceptional cover with unlimited hospital cover and above average day-to-day benefits, consisting of a savings account and flexible risk cover. Additional cover for specified services is available once the savings account and flexi-risk benefits are exhausted.
The SYMMETRY ED option is a new generation option that offers exceptional cover, with unlimited hospital cover within the Netcare Group of private hospitals. The plan offers superior day-to-day benefits consisting of a savings account and flexible risk cover. Additional cover for specified services is available once the savings account and flexi risk benefits are exhausted.
SYMMETRY / SYMMETRY ED
The UNISAVE option offers comprehensive unlimited hospital cover. A flexible savings account allows a member to pay for day-to-day healthcare requirements at the member’s own discretion.
UNISAVE
The MUMED option is a traditional option that offers a substantial cover, with unlimited hospital cover and sufficient day-to-day benefits consisting of flexible risk cover. Additional cover for specified services are available once the flexi-risk benefit is exhausted.
The MUMED ED option is a traditional option that offers above average cover, with unlimited hospital cover, within the Netcare Group of private hospitals. The plan offers day-to-day benefits consisting of flexible risk cover. Additional cover for specified services are available once the flexi-risk benefit is exhausted.
MUMED / MUMED ED
The AXIS option is a premium comprehensive private hospital benefit plan with post-operative rehabilitation benefits, as well as wellness benefits, for complete peace of mind.
The AXIS ED option is a premium comprehensive private hospital benefit plan within the Netcare Group of private hospitals. The plan offers post-operative rehabilitation benefits, as well as wellness benefits, for complete peace of mind.
AXIS / AXIS ED
The NETWORX option is an affordable healthcare plan offering exceptional value to students and lower-income employees, and provides essential cover within the Universal Healthcare Provider Network.
The NETWORX ED option is an affordable healthcare plan with exceptional value for lower-income employees. The plan offers comprehensive hospital benefits within a network of public and private hospitals and offers essential day-to-day cover within the Universal Healthcare Provider Network.
NETWORX / NETWORX ED
&FEATURESHIGHLIGHTS
Physical inactivity is now identified as the fourth leading risk factor for global mortality, followed by being overweight and obesity. Staying fit and healthy is a life long struggle that requires motivation in abundance. From being able to swim that extra length, or run another kilometre to achieving your perfect curves. Finding that boost of energy when all you want to do is reach for the snooze button is what it’s all about, and that’s where we come in to assist you.
COME ON, LAZY BONES! GET ACTIVE!Whether you’re a gym bunny nursing your six pack, someone undergoing rehabilitation following a major injury
or operation, or an average Joe or Jane wanting to improve your physical health and doing the Argus in under four hours, we’ve got something for you. The World Health Organisation now regards exercise as a treatment, and exercise prescription is an evidence-based way of treating illness and disabilities, and ensuring wellness. They recommend that adults aged 18 – 64 should do a minimum of 150 – 300 minutes of moderate-intensity exercise per week. Sign up for our scientific Fitness Assessment and Exercise Prescription Programme to benefit from regular interaction and monitoring, courtesy of one of our registered biokineticists and exercise facilities. And the sweetener? You can do this without having to pay gym fees.
EAT HEALTHY AND LOSE THOSE EXCESS KILOS While you’re at it, you may want to start eating healthier too. If food were a drug, for sure we’d have rehabilitation centres devoted to treating it much like those for drugs and alcohol. We have help available! Get going by signing up for our Nutritional Assessment and Healthy Eating programme which provides a consultation with a registered dietitian with a personalised health eating plan to help you achieve your goals, whether it be losing weight or eating correctly for health reasons, or following a top achiever sports nutrition programme. Remember, excuses don’t burn calories. Sign up today.
JUMPSTARTYOUR BODY
Available on all options except the NETWORX option range.
/ Member Scheme Benefit Options / CompCare Wellness Medical Scheme / 2019PAGE 3
/ Member Scheme Benefit Options / CompCare Wellness Medical Scheme / 2019 PAGE 4
As parents we know what it’s like to never be able to sleep in our own bed. We also understand that ‘action in the bedroom’ is likely to mean chasing a naked toddler while juggling a nappy, pyjamas and
a Sippy cup. Like you, we love our children and we know that they are the future. That is why we have designed a special “kid’s range of benefits” to ensure that their every health and wellness need is catered for. From baby wellness visits to childhood immunisations, school readiness assessments, pre-school eye, hearing and a dental screening – we’ve got your precious ones well cared for. For every child younger than six years you also get two additional GP visits and an extra visit
to an emergency room every year. For 2019, we’ve also added a consultation with an occupational therapist, a fitness assessment and exercise prescription programme, as well as a nutritional
assessment and healthy eating plan specially for kids. Now all you have to do is catch your toddler!
THE MANY WAYS WE FOCUS ON
KIDS
HEALTHCARE OF SUBSTANCE FOR WOMEN OF SUBSTANCEWe know that women hold up at least half the sky and in-between juggling work commitments and caring for their families, they’ll be busy multitasking something. Women tend to be great at prioritising the healthcare needs of others ahead of their own. This is why we’re always encouraging you to invest in some self-care. Take advantage of the routine health screenings on offer, which are appropriate to your individual stage of life and lifestyle. And do remember the importance of having a regular mammogram; we know it’s not fun but it is very necessary. Among the exciting new benefits we have lined up for you is an annual benefit for contraceptives, including Intrauterine devices (IUDs) and oral contraceptives.
Did you know that prostate problems are one of the most common conditions affecting men today? With more than 4 000 men, some as young as 40, being diagnosed with prostate cancer in South Africa every year. A prostate check, together with a prostate specific antigen (PSA) blood test, is certainly the right thing to do. Your PSA test is a guaranteed benefit, and paid from the scheme’s risk pool, so there is no reason not to go!
LADIES FIRST
LISTEN UP GENTSPROSTATE CHECKS – YOUR HEALTH IN A NUTSHELL… (NO PUN INTENDED)
Available on all options except the NETWORX option range.
/ Member Scheme Benefit Options / CompCare Wellness Medical Scheme / 2019PAGE 5
ADVENTURE SEEKERS – NOW YOU CAN REALLY PLAY!
&FEATURES
So, you love the outdoors and that rush of adrenalin just before you take the plunge skydiving, racingdown a steep mountain with your new bike, or watching the lights go out as you floor the accelerator, burning rubber in your suped up twin-turbo race car down the main straight… We’re big on life and on living life to the fullest. We share your taste for adventure – your need to soar, glide the thermals, or ride the waves – no matter what your game may be. No matter whether you’re a professional sport junky, or a weekend climbing enthusiast, we’ve got you covered. We’ve got the ultimate package for you. From access to selected sport supplements to wearable fitness and health monitoring devices, we’ll pay for it from your savings account (provided there is a valid NAPPI code - subject to sub-limits), we never compromise on care and if you get injured or ill, we’ll send in the cavalry (and the search and rescue if need be).
HIGHLIGHTS
LOVE EXTREME SPORTS? YOU’RE
COVERED!
Available on all options with a savings account. Subject to sub-limits.
/ Member Scheme Benefit Options / CompCare Wellness Medical Scheme / 2019 PAGE 6
ARE YOU EMOTIONALLY FIT AND STRONG?According to a recent study conducted in South Africa, 30.3% of adults will have suffered from some form of mental disorder in a lifetime. In the twelve months covered by the study around one in six adults – or 16.5% – suffered from common mental disorders. A quarter of these cases were classified as serious, which represents about four out of every hundred South Africans. When it comes to your emotional health and wellbeing, we’ve got you covered, having taken extra care to ensure that you have the necessary benefits at your disposal when you need them most. We offer a 24-hour help-line with trained clinical professionals to assist, and a referral for face-to-face counselling is also available as part of your benefit package.
Did you know that as many as a quarter of South Africans have either personally been diagnosed, or have a loved one, family, friend or colleague with cancer? As many as 100 000 South Africans are diagnosed with cancer every year. We offer a specialised cancer treatment programme with unlimited cover, subject to our treatment protocols.
WE DON’T COMPROMISE ON CANCER CARE
/ Member Scheme Benefit Options / CompCare Wellness Medical Scheme / 2019PAGE 7
COMPCARE OPTIONS AND BENEFITS FOR 2019
BENEFIT SCHEDULE PINNACLE DYNAMIX SYMMETRY MUMED UNISAVE AXIS NETWORX
IN-HOSPITAL BENEFITS
Hospitalisation - private hospitals and nursing homes
100% of the scheme rate.Cover provided in a private
ward. Treatment subject to pre-authorisation,
case management and scheme protocols
100% of the scheme rate.Treatment subject to
pre-authorisation,case management and scheme
protocols
100% of the scheme rate.Treatment subject to
pre-authorisation,case management and scheme
protocols
100% of the scheme rate.Treatment subject to
pre-authorisation,case management and scheme
protocols
100% of the scheme rate.Treatment subject to
pre-authorisation,case management and scheme
protocols
100% of the scheme rate.Treatment subject to
pre-authorisation,case management and scheme
protocols
Network of private hospitals. 100% of the scheme rate. Treatment subject to pre-
authorisation,case management and scheme
protocols
Efficiency Discounted (ED) Option. Members can select Designated Service Providers (DSP’s) for in-hospital services and chronic medicines upon which contributions will be discounted. Voluntary admission to a non-Netcare facility will attract a co-payment of 30% with a minimum of R5 000 (not applicable to emergencies). Voluntary use of a non-DSP pharmacy will result in a 25% co-payment.
Netcare hospitals and chronic medicines from a Dis-Chem
pharmacy - including Dis-Chem Courier pharmacies
Netcare hospitals and chronic medicines from a Dis-Chem
pharmacy - including Dis-Chem Courier pharmacies
Netcare hospitals and chronic medicines from a Dis-Chem
pharmacy - including Dis-Chem Courier pharmacies
Netcare hospitals and chronic medicines from a Dis-Chem
pharmacy - including Dis-Chem Courier pharmacies
No ED option
Netcare hospitals and chronic medicines from a Dis-Chem
pharmacy- including Dis-Chem Courier pharmacies
Network of private and public hospitals
Overall Annual Limit (OAL) Unlimited Unlimited Unlimited Unlimited Unlimited Unlimited R1 218 000 PMF.PMBs unlimited
Co-payments and exclusions See list of co-payments See list of co-payments See list of co-payments See list of co-payments See list of co-payments See list of co-payments and exclusions See list of exclusions
GPs and specialists
Unlimited. Specialists paid at 200% of the scheme rate (excluding dental treatment) and GPs paid at 100% of the
scheme rate
Unlimited. 100% of the scheme rate
Unlimited. 100% of the scheme rate
Unlimited. 100% of the scheme rate
Unlimited. 100% of the scheme rate
Unlimited. 100% of the scheme rate
Limited to OAL. 100% of the scheme rate
Medication - only while in hospital 100% of cost 100% of cost 100% of cost 100% of cost 100% of cost 100% of cost 100% of the scheme cost. Limited to OAL.
Medication on discharge from hospital (TTO) - subject to Reference Pricing (RP) and formularies
Limited to 7 days per discharge
Limited to 7 days per discharge
Limited to 7 days per discharge
Limited to 7 days per discharge
Limited to 7 days per discharge
Limited to 7 days per discharge
Limited to 7 days and R305 per discharge
Surgical prostheses
Subject to pre-authorisation and protocols. Limited to an overall limit of R46 960. Sub-
limits per category apply
Subject to pre-authorisation and protocols. Limited to an
overall limit of R40 000. Sub-limits per
category apply
Subject to pre-authorisation and protocols. Limited to an overall limit of R35 200. Sub-
limits per category apply
Subject to pre-authorisation and protocols. Limited to an overall limit of R32 850. Sub-
limits per category apply
Subject to pre-authorisation and protocols. Limited to an
overall limit of R31 400. Sub-limits per
category apply
Subject to pre-authorisation and protocols. Limited to an
overall limit of R30 500. Sub-limits per
category apply
PMB onlySubject to pre-authorisation
and protocols. Sub-limits apply. Limited to OAL
Auxillary services in-and-out of hospital, physiotherapy,psychology, etc.
Limited to R10 000 PMFSubject to pre-authorisation
and protocols. To be recommended by the treating
medical practitioner.
Limited to R7 000 PMFSubject to pre-authorisation
and protocols. To be recommended by the treating
medical practitioner.
Limited to R5 000 PMFSubject to pre-authorisation
and protocols. To be recommended by the treating
medical practitioner.
Limited to R3 000 PMFSubject to pre-authorisation
and protocols. To be recommended by the treating
medical practitioner.
Limited to R2 500 PMFSubject to pre-authorisation
and protocols. To be recommended by the treating
medical practitioner.
Limited to R2 500 PMFSubject to pre-authorisation
and protocols. To be recommended by the treating
medical practitioner.
Subject to clinical protocols. Limited to R2 500 PMF
Subject to pre-authorisation and protocols. To be
recommended by the treating medical practitioner.
/ Member Scheme Benefit Options / CompCare Wellness Medical Scheme / 2019 PAGE 8
COMPCARE OPTIONS AND BENEFITS FOR 2019 (continued)
BENEFIT SCHEDULE PINNACLE DYNAMIX SYMMETRY MUMED UNISAVE AXIS NETWORX
IN-HOSPITAL BENEFITS (continued)
Psychiatric treatment in hospital
21 days PMF in a hospital with a psychiatric facility
or a mental health institution. Subject to pre-authorisation and protocols and PMBs
21 days PMF in a hospital with a psychiatric facility
or a mental health institution. Subject to pre-authorisation and protocols and PMBs
21 days PMF in a hospital with a psychiatric facility
or a mental health institution. Subject to pre-authorisation and protocols and PMBs
21 days PMF in a hospital with a psychiatric facility
or a mental health institution. Subject to pre-authorisation and protocols and PMBs
21 days PMF in a hospital with a psychiatric facility
or a mental health institution. Subject to pre-authorisation and protocols and PMBs
21 days PMF in a hospital with a psychiatric facility
or a mental health institution. Subject to pre-authorisation and protocols and PMBs
21 days PMF in a hospital with a psychiatric facility
or a mental health institution. Subject to pre-authorisation and protocols and PMBs
Psychology(non-psychiatric admissions) Limited to R3 870 PMF Limited to R3 310 PMF Limited to R2 760 PMF Limited to R2 210 PMF Limited to R1 650 PMF Limited to R1 650 PMF No benefit
All specialised radiology including MRI, CT and PET scans
100% of the scheme rate. Unlimited.
Pre-authorisation required for all MRI and CT scans. High resolution CT Scans/
PET scans subject to special medical motivation and pre-authorisation. No benefit for unauthorised
scans. No benefit for screening purposes. The first R2 500 paid from available PMSA.
Accumulates to threshold, except PMBs
100% of the scheme rate. Unlimited. Pre-
authorisation required for all MRI and CT scans. High resolution CT scans/PET scans subject to special medical motivation and pre- authorisation. No
benefit for unauthorised scans.
No benefit for screening purposes. The first R2 250 paid from available PMSA.Accumulates to threshold,
except PMBs
100% of the scheme rate. Limited to R27 620 per
annum unless otherwise pre-authorised.
Pre-authorisation required for all MRI and CT scans. High resolution CT scans/
PET scans subject to special medical motivation and pre- authorisation. No benefit for unauthorised
scans.No benefit for screening
purposes. The first R1 500 is paid from available
PMSA
100% of the scheme rate. Limited to R24 300 per
annum unless otherwise pre-authorised. Pre-
authorisation required for all MRI and CT scans. High resolution CT scans/PET scans subject to special medical motivation and pre- authorisation. No
benefit for unauthorised scans. No benefit for screening purposes
100% of the scheme rate. Limited to R19 890 per
annum unless otherwise pre-authorised. Pre-
authorisation required for all MRI and CT scans. High resolution CT scans/PET scans subject to special medical motivation and pre-authorisation. No
benefit for unauthorised scans. No benefit for
screening purposes. The first R1 000 is paid from
available PMSA
100% of the scheme rate. Limited to R22 100 per
annum unless otherwise pre-authorised. Pre-
authorisation required for all MRI and CT scans. High resolution CT scans/PET scans subject to special medical motivation and pre- authorisation. No
benefit for unauthorised scans. No benefit for screening purposes
100% of the scheme rate, subject to protocols and
DSP.Pre-authorisation required for all MRI and CT scans. High resolution CT scans/
PET scans subject to special medical motivation and pre-authorisation. No benefit for unauthorised
scans.No benefit for screening
purposes. Subject to OAL. PMBs only
Basic radiology100% of the scheme rate.
Unlimited. Subject to scheme protocols
100% of the scheme rate. Unlimited. Subject to
scheme protocols
100% of the scheme rate. Unlimited. Subject to
scheme protocols
100% of the scheme rate. Unlimited. Subject to
scheme protocols
100% of the scheme rate. Unlimited. Subject to
scheme protocols
100% of the scheme rate. Unlimited. Subject to
scheme protocols
100% of the scheme rate. Unlimited. Subject to
scheme protocols
Pathology100% of the scheme rate.
Unlimited. Subject to scheme protocols
100% of the scheme rate. Unlimited. Subject to
scheme protocols
100% of the scheme rate. Subject to scheme protocols. Combined in-
and-out of hospital limit of R33 150 PMF
100% of the scheme rate. Subject to scheme protocols. Combined in-
and-out of hospital limit ofR30 380 PMF
100% of the scheme rate. Subject to scheme protocols. Combined in-
and-out of hospital limit ofR27 620 PMF
100% of the scheme rate. Subject to scheme protocols. Combined in-
and-out of hospital limit ofR24 860 PMF
100% of the scheme rate. Subject to OAL, case
management and protocols
Confinements
100% of the scheme rate. Subject to
pre-authorisation and protocols.2 x 2D Scans
100% of the scheme rate. Subject to
pre-authorisation and protocols.2 x 2D Scans
100% of the scheme rate. Subject to
pre-authorisation and protocols.2 x 2D Scans
100% of the scheme rate. Subject to
pre-authorisation and protocols.2 x 2D Scans
100% of the scheme rate. Subject to
pre-authorisation and protocols.2 x 2D Scans
Subject topre-authorisation
and protocols.2 x 2D Scans
Subject topre-authorisation
and protocols.2 x 2D Scans
Alcoholism, drug dependence and narcotics PMBs only PMBs only PMBs only PMBs only PMBs only PMBs only PMBs only
Organ transplants, plasmapheresis, renal dialysis
Subject to pre-authorisation and
protocols. PMBs only – refer to scheme rules
for details
Subject to pre-authorisation and
protocols. PMBs only – refer to scheme rules
for details
Subject to pre-authorisation and
protocols. PMBs only – refer to scheme rules
for details
Subject to pre-authorisation and
protocols. PMBs only – refer to scheme rules
for details
Subject to pre-authorisation and
protocols. PMBs only – refer to scheme rules
for details
Subject to pre-authorisation and
protocols. PMBs only – refer to scheme rules
for details
Subject to pre-authorisation and
protocols. PMBs only – refer to scheme rules
for details
Professional sports injuriesSubject to
pre-authorisationand protocols
Subject to pre-authorisation
and protocols
Subject to pre-authorisation
and protocols
Subject to pre-authorisation
and protocols
Subject to pre-authorisation
and protocols
Subject to pre-authorisation
and protocols
Subject to pre-authorisation
and protocols
/ Member Scheme Benefit Options / CompCare Wellness Medical Scheme / 2019PAGE 9
COMPCARE OPTIONS AND BENEFITS FOR 2019 (continued)
BENEFIT SCHEDULE PINNACLE DYNAMIX SYMMETRY MUMED UNISAVE AXIS NETWORX
ALTERNATIVES TO HOSPITALISATION
Oncology including chemotherapy and radiotherapy
Unlimited. Subject to pre-authorisation and protocols. Oncology
formulary applies
Unlimited. Subject to pre-authorisation and protocols. Oncology
formulary applies
Unlimited. Subject to pre-authorisation and protocols. Oncology
formulary applies
Unlimited. Subject to pre-authorisation and protocols. Oncology
formulary applies
Unlimited. Subject to pre-authorisation and protocols. Oncology
formulary applies
Unlimited. Subject to pre-authorisation and protocols. Oncology
formulary applies
Unlimited. Subject to pre-authorisation and protocols. Oncology
formulary applies
Biological agents and specialised medication
Pre-authorisation required. R273 000 PMF. Protocols
apply
Pre-authorisation required. R204 440 PMF. Protocols
apply. 25% co-payment on non-PMB medicines
Pre-authorisation required. R137 020 PMF. Protocols
apply. 25% co-payment on non-PMB medicines
Pre-authorisation required. R137 020 PMF. Protocols
apply. 25% co-payment on non-PMB medicines
Pre-authorisation required. R137 020 PMF. Protocols
apply. 25% co-payment on non-PMB medicines
Pre-authorisation required. R137 020 PMF. Protocols
apply. 25% co-payment on non-PMB medicines
PMBs only. Subject to protocols and OAL
Step-down nursing facilities, hospice and rehabilitation
Unlimited. Subject to pre-authorisation and
clinical guidelines
Unlimited. Subject to pre-authorisation and
clinical guidelines
Unlimited. Subject to pre-authorisation and
clinical guidelines
Unlimited. Subject to pre-authorisation and
clinical guidelines
Unlimited. Subject topre-authorisation and
clinical guidelines
Unlimited. Subject to pre-authorisation and
clinical guidelines
Limited to OAL. Subject to pre-authorisation and
clinical guidelines
Surgical procedures out-of-hospitalUnlimited. Subject to
pre-authorisation and protocols
Unlimited. Subject to pre-authorisation
and protocols
Unlimited. Subject to pre-authorisation
and protocols
Unlimited. Subjectto pre-authorisation
and protocols
Unlimited. Subjectto pre-authorisation
and protocols
No benefit unless in lieuof hospitalisation. Subject
to pre-authorisationand protocols
Limited to OAL. Subject to pre-authorisation.
Procedures in GP’s rooms subject to DSP only.
Procedures in specialist’s rooms subject to
referral by Universal Network GP
Radial keratotomy and excimer laser
Annual limit of R6 890 per eye. Subject to pre-
authorisation and protocols. Limit include all services rendered: hospitalisation
and all related costs
Annual limit of R6 180 per eye. Subject to pre-
authorisation and protocols. Limit include all services rendered: hospitalisation
and all related costs
Annual limit of R4 640 per eye. Subject to pre-
authorisation and protocols.Limit include all services rendered: hospitalisation
and all related costs
Subject to optical benefit. Subject to
pre-authorisation and protocols
Subject to optical benefit. Subject to
pre-authorisation and protocols
PMBs only No benefit
Wound care in lieu of hospitalisationUnlimited. Subject to
pre-authorisation and protocols
Unlimited. Subject to pre-authorisation
and protocols
Unlimited. Subject topre-authorisation
and protocols
Unlimited. Subject topre-authorisation
and protocols
Unlimited. Subject topre-authorisation
and protocols
Unlimited. Subject topre-authorisation
and protocols
Limited to OAL. Subject topre-authorisation
and protocols
/ Member Scheme Benefit Options / CompCare Wellness Medical Scheme / 2019 PAGE 10
COMPCARE OPTIONS AND BENEFITS FOR 2019 (continued)
BENEFIT SCHEDULE PINNACLE DYNAMIX SYMMETRY MUMED UNISAVE AXIS NETWORX
DAY-TO-DAY BENEFITS
Day-to-day benefits
Claims are paid initially from the annual Personal
Medical Savings Account (PMSA).
Once the PMSA becomes exhausted claims are paid
from the Annual Flexi Benefit (AFB), where after
the member will be liable for the
Self-payment Gap (SPG). During this period, claims
will accumulate to the annual threshold at the scheme rate. Once the
annual threshold is reached, specific Above Threshold Benefits (ATB) will be available up to a
limit ofR8 710 PB and R17 720 PMF – further sub-limits
apply
Claims are paid initially from the annual Personal
Medical Savings Account (PMSA).
Once the PMSA becomes exhausted claims are
paid from an Annual Flexi Benefit (AFB), where after
the member is then liable for the
Self-payment Gap (SPG). During this period, claims
will accumulate to the threshold level at the
scheme rate. Once the threshold level is reached, specific Above Threshold
Benefits (ATB) will be available up to a limit of R6 410 PB and R11 320 PMF – further sub-limits
apply
Claims are paid initially from the annual Personal Medical Savings Account
(PMSA). Once PMSA becomes exhausted claims are paid from the Annual Flexi Benefit (AFB). Total
annual day-to-day benefits:Normal Option:
P: R8 981, A: R6 978 C: R2 506
When AFB is exhausted additional benefits
are available
Benefits are paid from the Annual Flexi Benefit (AFB).
AFB limits:Normal Option: P: R5 940,
A: R3 720 C: R1 480
When AFB is exhausted additional benefits
are available
Claims are paid from the annual Personal Medical Savings Account (PMSA):
P: R7 116, A: R6 072C: R2 136
Post-operative rehabilitation – physiotherapy,
occupational therapy and biokinetics. Limited to R3 420 PB per annum
14 Days
Must be pre-authorised. Protocols apply
Only applies to PMBs
If services are rendered by Universal Network
Providers, benefits will be paid at 100% of
the scheme rate up to specified limits.
Specialist visits, basic dentistry, optometry, and
non-formulary prescription medication are subject to the Annual Flexi Benefit
(AFB), limited to:R3 080 PB and
R4 600 PMF
General practitioners
100% of the scheme rate. Include consultation fees,
procedure and material costs.
Subject to PMSA, AFB and SPG. After threshold unlimited
100% of the scheme rate. Include consultation fees,
procedure and material costs.
Subject to PMSA, AFB and SPG. After threshold unlimited
100% of the scheme rate. Include consultation fees,
procedure and material costs.
Paid from PMSA and AFB.Once PMSA and AFB are exhausted consultations
(excluding procedures and materials) are unlimited
100% of the scheme rate. Include consultation fees, procedure and material
costs.
Paid from AFB first, limited toM: 6 visits,
M+1: 8 visits,M+2: 10 visits,M+3+: 11 visits
Once AFB is exhausted, the balance of visits are available and paid from
risk (excluding procedures and materials)
Paid from PMSA PMBs only
Unlimited at a Universal Network GP.
2 visits PB outside of the Universal Network
per annum. For out-of-network visits, a20% co-payment applies.
Members are required to pay at the point of
service and claim back from the Scheme. Limited
to a R1 100 per event (including medicine,
pathology and radiology), excluding facility fees
/ Member Scheme Benefit Options / CompCare Wellness Medical Scheme / 2019PAGE 11
COMPCARE OPTIONS AND BENEFITS FOR 2019 (continued)
BENEFIT SCHEDULE PINNACLE DYNAMIX SYMMETRY MUMED UNISAVE AXIS NETWORX
DAY-TO-DAY BENEFITS
Specialists
200% of the scheme rate. Initially paid from PMSA,
AFB and SPG.Thereafter an ATB of
R4 620 PMF apply, subject to overall above threshold
limit. Referral from a GP required
100% of the scheme rate. Initially paid from PMSA,
AFB and SPG.Thereafter an ATB of
R3 980 PMF apply, subject to overall above threshold limit. A 30% co-payment
will apply to specialist services, including related
costs, e.g. pathology and radiology without
GP referral.
100% of the scheme rate.Paid from PMSA and AFB.
Referral from a GP required. A 30%
co-payment will apply to specialist services,
including related costs, e.g. pathology and radiology
without GP referral.
100% of the scheme rate.Paid from AFB. Referral
from a GP required. A 30% co-payment will
apply to specialist services, including related costs, e.g.
pathology and radiology without GP referral.
100% of the scheme rate.Paid from PMSA. Referral
from a GP required. A 30% co-payment will
apply to specialist services, including related costs, e.g.
pathology and radiology without GP referral.
PMBs only
100% of the scheme rate.2 visits PB - max 3 PMF per
annum. Two additional antenatal visits per
pregnancy. Subject to referral by a DSP network GP and pre-authorisation
of each specialist visit. Referrals limited to
specialists located at DSP Network hospitals only.
Subject to AFB
Chronic medicines
Subject to formulary. RP applies. 73 conditions
(27 CDL conditions +46 non-CDL conditions).Unlimited for registered
CDL conditions.Non-CDL chronic
medication is paid from PMSA, AFB and SPG first.
Limited to R12 260 PB andR18 375 PMF.
ATB limited to R4 620 PMF, subject to the overall
Above Threshold Limit.
Subject to formulary. RP applies. 64 conditions
(27 CDL conditions +37 non-CDL conditions).Unlimited for registered
CDL conditions. Paid from AFB first.
Non-CDL Chronic medication is paid from
PMSA, AFB and SPG first. Limited to R9 220 PB,
and R15 410 PMF.ATB limited to R3 060
PMF, subject to the overall Above Threshold Limit
Subject to formulary. RP applies. 47 conditions(27 CDL conditions + 20
non-CDL conditions)27 CDL conditions subject
to AFB.Non-CDL conditions
subject to PMSA and AFB.Limited to R4 530 PB,
R6 800 PMF.Once benefit depleted CDL
medicines unlimited
Subject to formulary. RP applies.
Unlimited for 37 conditions (27 CDL conditions + 10
non-CDL conditions).Subject to AFB. Once AFB is depleted CDL medicines
are unlimited
Subject to formulary.RP applies. Unlimited for
the 27 CDL conditions
Subject to formulary RP applies. Unlimited for
the 27 CDL conditions
Subject to formulary RP applies. Unlimited for
the 27 CDL conditions - unlimited only if
prescribed by a Universal Network provider
and dispensed within a Universal Network
pharmacy or dispensing DSP doctor. Any voluntary use of chronic medicine
prescribed by out-of-network provider
and any non- formulary medicines are for
member’s own account, unless pre-authorised by
the medical advisor.PMB rules apply
Acute medicines - schedule 3 and higher
Initially paid from PMSA, AFB and SPG. Thereafter an ATB of R3 830 PMF, subject to overall ATB.A 25% co-payment is
applicable to non-generic products. MMAP applies.
Initially paid from PMSA, AFB and SPG. Thereafter an ATB of R3 090 PMF, subject to overall ATB.A 25% co-payment is
applicable to non-generic products. MMAP applies.
Paid from PMSAand AFB.
A 25% co-payment is applicable to non-generic products. MMAP applies.
Paid from AFB.A 25% co-payment is
applicable to non-generic products. MMAP applies.
Paid from PMSA PMBs only
Unlimited if prescribed by a Universal Network GP,
or by a specialist provided member was referred by a Universal Network GP. Subject to formulary. No cover for non-formulary
medicines unless otherwise pre-authorised.
No cover in cases of voluntary use of
non-DSPs, or voluntary use of specialists without
referral by a Universal Network GP
/ Member Scheme Benefit Options / CompCare Wellness Medical Scheme / 2019 PAGE 12
COMPCARE OPTIONS AND BENEFITS FOR 2019 (continued)
BENEFIT SCHEDULE PINNACLE DYNAMIX SYMMETRY MUMED UNISAVE AXIS NETWORX
DAY-TO-DAY BENEFITS (continued)
Over the counter medication - including schedule 0, 1 and 2 medicines and homeopathic medicines
Subject to PMSA and AFB.Max per event R210.
Subject to RP. Limited to R1 020 PB and R1 450
PMF. Does not accumulate to threshold
Subject to PMSA and AFB. Max per event R200.
Subject to RP.Limited to
R880 PB and R1 320 PMF. Does not accumulate
to threshold
Paid from PMSA and AFB. Limited to R710 PB andR1 160 PMF. Max per
event R180. Subject to RP
Paid from AFB Limited to R580 PB and R1 050 PMF.
Max per event R170. Subject to RP
Paid from PMSA. Limited to R550 PB and R990 PMF.
Max per event R160. Subject to RP
No benefit No benefit
Basic radiology - X-rays including black and white X-rays and Ultrasound
Pregnancy scans limited to two 2D scans
100% of the scheme rate. Initially paid from PMSA, AFB and SPG. Thereafter
an ATB ofR4 610 PMF apply, subject to overall ATB. Combined ATB limit with pathology
100% of the scheme rate. Initially paid from PMSA, AFB and SPG. Thereafter
an ATB ofR3 070 PMF apply, subject to overall ATB. Combined ATB limit with pathology
100% of the scheme rate.Paid from PMSA and AFB
100% of the scheme rate.Paid from AFB
100% of the scheme rate.Paid from PMSA In-hospital benefit only
100% of the scheme rate. Unlimited when clinically
appropriate within the Universal Network and subject to referral by a Universal Network GP. Limited to list of
codes. Subject to case management.
No benefit if not referred by a Universal Network
provider, or by a specialist following referral by a Universal Network GP
(except when involuntary)
All specialised radiology including MRI, CT and PET scans
Combined with in-hospital specialised radiology
benefit. The first R2 500 is payable from the PMSA, AFB and SPG with
accumulation tothe threshold
Combined with in-hospital specialised radiology
benefit. The first R2 250 is payable from the PMSA, AFB and SPG with
accumulation to the threshold
Combined with in-hospital specialised radiology
benefit. Limited toR27 620 PMF.
The first R1 500 is payable from the PMSA and AFB
Combined with in-hospital specialised radiology
benefit. Limited toR24 300 PMF
100% of the scheme rate. Subject to PMSA In-hospital benefit only
100% of the scheme rate.PMBs only. Subject to pre-authorisation and
case management
Pathology
100% of the scheme rate. Initially paid from PMSA, AFB and SPG. Thereafter
an ATB of R4 620 PMF apply, subject to overall ATB. Combined ATB limit
with radiology
100% of the scheme rate. Initially paid from PMSA, AFB and SPG. Thereafter
an ATB of R3 070 PMF apply, subject to overall ATB. Combined ATB limit
with radiology
100% of the scheme rate. Paid from PMSA and
AFB subject to scheme protocols. Combined
in-and-out of hospital limit of R33 150 PMF
100% of the scheme rate. Subject to AFB
100% of the scheme rate. Subject to PMSA PMBs only
100% of the scheme rate. Unlimited when clinically appropriate within a DSP Network and subject to
referral by a DSP network GP. Limited to list of
codes. Subject to case management. No benefit if not referred by a Universal Network provider, or by a
specialist following referral by a DSP network GP
(except when involuntary)
Conservative dentistry including consultations, preventative care, fillings, extractions and infection control
100% of the scheme rate. Subject to PMSA, AFB
and SPG. After threshold unlimited
100% of the scheme rate. Subject to PMSA,
AFB and SPG
100% of the scheme rate. Subject to PMSA and AFB.
100% of the scheme rate. Subject to AFB
100% of the scheme rate. Subject to PMSA PMBs only
100% of the scheme rate at a Universal Network
dentist. 1 Consultation per PB per annum. Limited to
R1 575 PB and R2 620 PMF
/ Member Scheme Benefit Options / CompCare Wellness Medical Scheme / 2019PAGE 13
COMPCARE OPTIONS AND BENEFITS FOR 2019 (continued)
BENEFIT SCHEDULE PINNACLE DYNAMIX SYMMETRY MUMED UNISAVE AXIS NETWORX
DAY-TO-DAY BENEFITS (continued)
Specialised dentistry, including maxillofacial and oral surgery - in-and-
out of hospital combined limit
100% of the scheme rate. Paid from PMSA and AFB, subject to a sub-limit of
R17 680 PB.Subject to protocols.
Orthodontic treatment limited to R17 500
per lifetime
100% of the scheme rate. Paid from PMSA and AFB, subject to a sub-limit ofR11 600 PB and R16 120
PMF. Subject to protocols. Orthodontic treatment
limited to R17 500 per lifetime
100% of the scheme rate.Paid from family PMSA and
AFB. Limited toR7 720 PB. Subject to
scheme protocols.Implants: for member’s account. Orthodontic treatment limited to R17 500 per lifetime
100% of the scheme rate.Paid from AFB. Limited to
R2 050 PB. Subject to scheme
protocols Implants for member’s account
100% of the scheme rate. Subject to PMSA PMBs only PMBs only, subject to AFB
Optometry visits Subject to PMSA and AFB. 2 visits PB per annum
Subject to PMSA and AFB. 2 visits PB per annum
Subject to PMSA and AFB. 1 visit PB every
second year
Subject to AFB. 1 visit PB every second year
Subject to PMSA. 1 Visit PB every second year PMBs only
Subject to AFB. 1 Visit PB every second year
at a Universal Network optometrist
Lenses, frames and contact lenses
100% of the scheme rate. Paid from PMSA and AFB, subject to a sub-limit of
R4 620 PB. Subject to protocols
100% of the scheme rate. Paid from PMSA and AFB, subject to a sub-limit of
R3 700 PB. Subject to protocols
100% of the scheme rate. Paid from PMSA and AFB, subject to a sub-limit of R2 070 PB every second
year. Subject to protocols
100% of the scheme rate. Paid from AFB, subject to a
sub-limit ofR1 590 PB and R4 550 PMF
every second year. Subject to protocols
100% of the scheme rate. Subject to PMSA.
Benefit available every second year
PMBs only
Clear plastic single vision (limited to R860) or
bi-focal lenses (limited to R1 380) every second year
at a Universal Network optometrist No benefit for
contact lenses. Subject to AFB
Frames
Sub-limit of R2 340 per frame. 1 frame PB per
annum, included in lenses limit
Sub-limit of R1 540 per frame. 1 frame PB per
annum, included in lenses limit
Sub-limit of R1 090 per frame. 1 frame PB every second year, included in
lenses limit
Sub-limit of R805 per frame. 1 frame PB every second year, included in
lenses limit
Subject to PMSA. Benefit available every
second yearPMBs only Included in lenses benefit
Speech therapists, social workers, podiatrists, occupational therapists,
homeopaths and naturopaths, dietitians, chiropractors (X-rays
excluded), audiologist, physiotherapy and biokinetics in-and-out of hospital
Subject to protocols
100% of the scheme rate. Initially paid from PMSA, AFB
and SPG up to a collective sub-limit of R10 000 PMF in-and-out of hospital. ATB limit of R2 890 for physiotherapy
and biokineticist, should overall auxillary limit not be
depleted
100% of the scheme rate. Initially paid from PMSA,
AFB and SPG up to a collective sub-limit of
R7 000 PMF in-and-out of hospital
100% of the scheme rate. Paid from PMSA and AFB.
Collective limit of R5 000 PMF
in-and-out of hospital
100% of the scheme rate. Paid from AFB. Collective
limit of R3 000 PMF in-and-out of hospital
100% of the scheme rate. Paid from PMSA PMBs only PMBs only
Clinical psychologists
100% of the scheme rate. Paid from PMSA and AFB
up to a sub-limit ofR5 050 PMF
100% of the scheme rate. Paid from PMSA and AFB
up to a sub-limit ofR2 320 PMF
100% of the scheme rate. Paid from PMSA and AFB
up to a sub-limit ofR1 890 PMF
100% of the scheme rate. Paid from AFB up to a
sub-limit of R1 650 PMF
100% of the scheme rate. Paid from PMSA PMBs only PMBs only
Surgical and medical appliancese.g. wheelchairs, crutches,
glucometers, hearing aids, artificial eyes and external fixators
Pre-authorisation required. Sub-limits and protocols
apply.Subject to PMSA and AFB
Pre-authorisation required. Sub-limits and protocols
apply.Subject to PMSA and AFB
Pre-authorisation required. Sub-limits and protocols
apply.Limited to PMSA and AFB
Pre-authorisation required. Sub-limits and protocols
apply.Subject to AFB
Pre-authorisation required. Sub-limits and protocols
apply.Subject to PMSA
PMBs only PMBs only
Psychiatry
100% of the scheme rate. Paid from PMSA and AFB
up to a sub-limit of R16 850 PMF
100% of the scheme rate. Paid from PMSA and AFB
up to a sub-limit ofR9 940 PMF
100% of the scheme rate. Paid from PMSA and AFB
up to a sub-limit ofR6 400 PMF
100% of the scheme rate. Paid from AFB
up to a sub-limit of R4 200 PMF
100% of the scheme rate. Paid from PMSA PMBs only PMBs only
/ Member Scheme Benefit Options / CompCare Wellness Medical Scheme / 2019 PAGE 14
COMPCARE OPTIONS AND BENEFITS FOR 2019 (continued)
BENEFIT SCHEDULE PINNACLE DYNAMIX SYMMETRY MUMED UNISAVE AXIS NETWORX
DAY-TO-DAY BENEFITS (continued)
Psychosocial counselling benefit
Unlimited telephonic counselling sessions with
psychologists or social workers with an option
for referral to one-on-one sessions with qualified psychologists or social
workers to a maximum of 3 referral sessions PB
per annum. Paid from risk
Unlimited telephonic counselling sessions with
psychologists or social workers with an option
for referral to one-on-one sessions with qualified psychologists or social
workers to a maximum of 3 referral sessions PB
per annum. Paid from risk
Unlimited telephonic counselling sessions with
psychologists or social workers with an option
for referral to one-on-one sessions with qualified psychologists or social
workers to a maximum of 3 referral sessions PB
per annum. Paid from risk
Unlimited telephonic counselling sessions with
psychologists or social workers with an option
for referral to one-on-one sessions with qualified psychologists or social
workers to a maximum of 3 referral sessions PB
per annum. Paid from risk
Unlimited telephonic counselling sessions with
psychologists or social workers with an option
for referral to one-on-one sessions with qualified psychologists or social
workers to a maximum of 3 referral sessions PB
per annum. Paid from risk
Unlimited telephonic counselling sessions with
psychologists or social workers with an option
for referral to one-on-one sessions with qualified psychologists or social
workers to a maximum of 3 referral sessions PB
per annum. Paid from risk
Unlimited telephonic counselling sessions with
psychologists or social workers with an option
for referral to one-on-one sessions with qualified psychologists or social
workers to a maximum of 3 referral sessions PB
per annum. Paid from risk
Oxygen home ventilation
100% of the scheme rate. Subject to pre-authorisation, protocols and PMBs. Subject
to PMSA and AFB
100% of the scheme rate. Subject to pre-authorisation, protocols and PMBs. Subject
to PMSA and AFB
100% of the scheme rate. Subject to pre-authorisation, protocols and PMBs. Subject
to PMSA and AFB
100% of the scheme rate. Subject to pre-
authorisation, protocols and PMBs. Subject to AFB
100% of the scheme rate. Subject to pre-
authorisation, protocols and PMBs. Subject to PMSA
PMBs only PMBs only
Private nursing homes100% of the scheme rate. Limited to 60 days PMF.
Subject to PMSA and AFB
100% of the scheme rate. Limited to 60 days PMF.
Subject to PMSA and AFB
100% of the scheme rate. Limited to 20 days PMF.
Subject to PMSA and AFB
100% of the scheme rate. Limited to 20 days PMF.
Subject to AFB
100% of the scheme rate. Limited to 20 days PMF.
Subject to PMSAPMBs only PMBs only
Ante-natal classes
100% of the scheme rate. Subject to PMSA and AFB.
Limited to 12 antenatal classes and a lactation
consultation with a midwife and limited to R1 310 per
pregnancy
100% of the scheme rate. Subject to PMSA and AFB.
Limited to 12 antenatal classes and a lactation
consultation with a midwife and limited to R1 300 per
pregnancy
100% of the scheme rate. Subject to PMSA and AFB.
Limited to 12 antenatal classes and a lactation
consultation with a midwife and limited to R960 per
pregnancy
100% of the scheme rate. Subject AFB. Limited to
12 antenatal classes and a lactation consultation with a midwife and limited to R750
per pregnancy
100% of the scheme rate. Subject to PMSA and AFB.
Limited to 12 antenatal classes and a lactation
consultation with a midwife and limited to R750 per
pregnancy
No benefit No benefit
Ante-natal visits 100% of the scheme rate. Limited to 12 ante-natal visits with a GP, Specialist or Midwife (In addition to normal benefits, not subject to PMSA and AFB). Maternity bag issued on registration on maternity programme No benefit
Emergency roadside assistance and ambulance transportation
100% of scheme rate with PP. In non-emergency cases, authorisation
must be obtained from the Designated Service Provider at the time of
transportation or within 24 hours thereof, failing
which will result in a 25% co-payment
100% of scheme rate with PP. In non-emergency cases, authorisation
must be obtained from the Designated Service Provider at the time of
transportation or within 24 hours thereof, failing
which will result in a 25% co-payment
100% of scheme rate with PP. In non-emergency cases, authorisation
must be obtained from the Designated Service Provider at the time of
transportation or within 24 hours thereof, failing
which will result in a 25% co-payment
100% of scheme rate with PP. In non-emergency cases, authorisation
must be obtained from the Designated Service Provider at the time of
transportation or within 24 hours thereof, failing
which will result in a 25% co-payment
100% of scheme rate with PP. In non-emergency cases, authorisation
must be obtained from the Designated Service Provider at the time of
transportation or within 24 hours thereof, failing
which will result in a 25% co-payment
100% of scheme rate with PP. In non-emergency cases, authorisation
must be obtained from the Designated Service Provider at the time of
transportation or within 24 hours thereof, failing
which will result in a 25% co-payment
100% of scheme rate with PP. In non-emergency cases, authorisation
must be obtained from the Designated Service Provider at the time of
transportation or within 24 hours thereof, failing
which will result in a 25% co-payment
International travel: Healthcare services while traveling outside of the borders of South Africa
Subject to benefits per individual benefit category. Paid at South African rates
Subject to benefits per individual benefit category. Paid at South African rates
Subject to benefits per individual benefit category. Paid at South African rates
Subject to benefits per individual benefit category. Paid at South African rates
Subject to benefits per individual benefit category. Paid at South African rates
Subject to benefits per individual benefit category. Paid at South African rates
Subject to benefits per individual benefit category. Paid at South African rates
Hospital emergency room and casualty emergency visits not requiring admissionExcluding facility fees 801 or 301
Paid from PMSA and AFB. Excluding facility fees
Paid from PMSA and AFB. Excluding facility fees
Paid from PMSA and AFB. Excluding facility fees
Paid from AFB. Excluding facility fees
Paid from PMSA. Excluding facility fees No benefit No benefit
Hospital emergency as a result of physical injury caused by an external force
100% of the scheme rate. Subject to protocols
and PMB
100% of the scheme rate. Subject to protocols
and PMB
100% of the scheme rate. Subject to protocols
and PMB
100% of the scheme rate. Subject to protocols
and PMB
100% of the scheme rate. Subject to protocols
and PMB
100% of the scheme rate. Subject to protocols
and PMB
100% of the scheme rate. Subject to protocols
and PMB
Child benefit If day-to-day benefits are depleted, members have access to two additional GP visits per annum per child younger than six years and one additional visit at an emergency room per annum per child younger than 6 years. Visit to emergency room is limited to R1 100 per event No benefit
/ Member Scheme Benefit Options / CompCare Wellness Medical Scheme / 2019PAGE 15
COMPCARE OPTIONS AND BENEFITS FOR 2019 (continued)
BENEFIT SCHEDULE PINNACLE DYNAMIX SYMMETRY MUMED UNISAVE AXIS NETWORX
WELLNESS BENEFITS
Wellness, lifestyle and preventative care
All benefits are paid from risk, except where otherwise indicated
GP wellness consultation: One visit PB per annum, excludes procedures. Limited to tariff code 0190/1/2 and ICD10 Z00.0 or Z00.1Blood pressure, blood sugar, cholesterol, BMI and waist circumference: One measurement PB over the age of 18 years, limited to R190 per event over the age of 18. Only at
DSP pharmacy Rapid HIV tests: 1 test PB per annum
Prophylaxis - malaria preventative medicine as requiredFlu Vaccine: Once per annum PB
Tetanus vaccine: One injection when requiredPSA (Prostate Specific Antigen): One test per male beneficiary over the age 40
Glaucoma test: One PB per annumPap smear: One test per female beneficiary over the age of 18 per annum
Mammogram: One test per female beneficiary over the age of 35 every second yearHPV (Cervical Cancer) vaccine: One course (3 doses per registered schedule) per female beneficiary between 12 and 18 years of age per lifetime
Adult pneumococcal vaccine PB as required, subject to pre-authorisationSubject to protocols
Fitness Assessment and exercise prescription: Access to Universal Network biokineticists for annual fitness assessment, exercise prescription and regular monitoring. One additional assessment per pregnant women per pregnancy. Strict protocols apply
Nutritional assessment and healthy eating plan: Access to the Universal Network of dietitians for annual assessment, healthy eating plan prescription and regular monitoring. One additional assessment per pregnant women per pregnancy. Strict protocols apply
Contraceptives: Limited to R2 640 per beneficiary per annum. For oral contraceptives, RP applies. For IUD benefit, device only.
Blood pressure, blood sugar, cholesterol, BMI.R190 PB over the age
of 18. Only at DSP pharmacy. Flu vaccine,
once per year PB
New-born to adult benefit
Subject to protocols
Baby wellness visit: Two visits per annum for children between 4 weeks and 18 months at a DSPChildhood immunisations: Applicable to children up to the age of 12 years, as per recommendation of the Department of Health
School readiness assessments: 5 - 7 years old Psychometric testing, 14 - 18 years, pre-school eye and hearing screening for children aged 5 and 6Dental screening for children 5 - 7 years old
Fitkids: Fitness assessment and exercise prescription for children between 8 and 12 years with a Universal Network biokineticist.SporTeen: Fitness assessment and exercise prescription for children between 13 and 17 years with a Universal Network biokineticist.
Nutrikids: Access to a Universal Network dietitian for nutritional assessments and assistance with a healthy eating plan for children from 8 years and older
Oral contraceptives, limited to R130 PB
per month
* All limits are pro-rated when a member or a beneficiary joins the scheme during the year, calculated from the date of registration to the end of that financial year. If you leave the Scheme before the year is up and have used all the funds in your savings account, you will owe the Scheme the advanced portion of the Medical Savings Account you have used as it is a pro-rated benefit allocated in advance for the full benefit year. This summary is for information purposes only and does not supersede the rules of the Scheme. In the event of a discrepancy between the summary and the rules, the rules will prevail.
/ Member Scheme Benefit Options / CompCare Wellness Medical Scheme / 2019 PAGE 16
CO-PAYMENTS 2019
PROCEDURE (NON-PMB) PINNACLE DYNAMIX SYMMETRY MUMED UNISAVE AXIS
Hospital cost only R R R R R R
Gastroscopy R1 970 R1 970 R2 625 R4 330 R4 330 R4 330Colonoscopy R1 970 R1 970 R2 625 R4 330 R4 330 R4 330Cystoscopy R1 970 R1 970 R2 625 R4 330 R4 330 R4 330Protoscopy - - R2 625 R4 330 R4 330 R4 330Nasal or sinus endoscopy R1 970 R1 970 R2 625 R4 330 R4 330 R4 330Functional nasal surgery and septoplasty R1 970 R1 970 R8 060 R8 060 R8 060 R8 060Hysteroscopy R1 970 R1 970 R2 625 R4 330 R4 330 R4 330Flexible sigmoidoscopy R1 970 R1 970 R2 625 R4 330 R4 330 R4 330Arthroscopy R1 970 R1 970 R2 625 R8 060 R8 060 R8 060Minor gynaecological laparoscopic procedure R1 970 R1 970 R2 625 R4 330 R4 330 R4 330Dental R1 970 R1 970 R2 625 R4 330 R4 330 R4 330Excision lesion - benign and malignant R1 970 R1 970 R1 310 R1 310 R1 310 R1 310Joint replacements - arthroplasty R1 970 R1 970 R20 000 R30 000 R30 000 R30 000Conservative back and neck treatment - spinal cord injections R1 970 R1 970 R15 000 R20 000 R20 000 R20 000Laminectomy and spinal fusion R1 970 R1 970 R25 000 R35 000 R35 000 R35 000Nissen fundoplication - reflux surgery R1 970 R1 970 R15 000 R20 000 R20 000 R20 000Hysterectomy, except for cancer R1 970 R1 970 R10 000 R15 000 R15 000 R15 000Laparoscopic hemi colectomy R1 970 R1 970 R3 930 R5 250 R5 250 R5 250Laparoscopic inguinal hernia repair R1 970 R1 970 R2 625 R5 250 R5 250 R5 250Laparoscopic appendectomy R1 970 R1 970 R2 625 R5 250 R5 250 R5 250Adenoidectomy, myringotomy - grommets, tonsillectomy - - R3 350 R3 340 R3 340 R3 340Laparoscopy, hysteroscopy, endometrial ablation - - R8 060 R8 060 R8 060 R8 060
EXCLUSIONSApart from the general exclusions of the scheme as listed under the hospitalisation section and related treatment for the following procedures are excluded, unless a PMB:
APPLICABLE TO THE AXIS OPTIONS:• Deep brain implants (e.g. for Parkinson’s Disease) and internal nerve stimulators • Corneal transplants • Cochlear implants • Bunion surgery
*Refer to page 23 for a list of scheme specific exclusions. (Scheme rules apply.)
APPLICABLE TO THE NETWORX OPTION:• Dentistry • All joint replacements, except in the event of acute injury• All spinal surgery (including neck), except in the event of acute injury• Deep brain implants (e.g. for Parkinson’s Disease) and internal nerve stimulators • Bunion surgery • Corneal transplants • Cochlear implants • Nissan fundoplication (Reflux surgery) • Brachytherapy for prostate cancer • Refractive eye surgery • Elective caesarean section • Treatment for obesity, skin disorders or functional nasal problems• Treatment for fibroadenosis
SCHEME SPECIFIC EXCLUSIONS*: 2019
/ Member Scheme Benefit Options / CompCare Wellness Medical Scheme / 2019PAGE 17
SUB-LIMITS FOR SURGICAL PROSTHESIS, ELECTRONIC AND NUCLEAR DEVICES AND APPLIANCES: 2019
Sub-limits for surgical prosthesis, electronic and nuclear devices and surgical appliances. Subject to PMBs, pre-authorisation and protocols and subject to the limit for these benefits on each option and subject tothese benefits being covered on each option.
SURGICAL INTERNAL PROSTHESIS DESCRIPTION FREQUENCY PINNACLE DYNAMIX SYMMETRY MUMED UNISAVE AXISOVERALL LIMITS ANNUAL R46 960 R40 000 R35 200 R32 850 R31 400 R30 500
2.1 Coronary artery stents (subject to overall limit)
Stents (max of 3) ANNUAL
Subject to overall annual limit and a
limit of R12 250 per stent
Subject to overall annual limit and a limit of R12 250
per stent
Subject to overall annual limit and a
limit of R12 250 per stent
Subject to overall annual limit and a limit of R12 250
per stent
Subject to overall annual limit and a limit of R12 250
per stent
Subject to overall annual limit and a limit of R12 250
per stent
Medicated stents (max 3 stents) ANNUAL
Subject to overall annual limit and a limit of R19 000
per stent
Subject to overall annual limit and a limit of R19 000
per stent
Subject to overall annual limit and a limit of R19 000
per stent
Subject to overall annual limit and a limit of R19 000
per stent
Subject to overall annual limit and a limit of R19 000
per stent
Subject to overall annual limit and a limit of R19 000
per stent
2.2 AAA stents (subject to overall limit)
Abdominal aorticaneurism stents
ANNUAL
Subject to overall annual limit
Subject to overall annual limit
Subject to overall annual limit
Subject to overall annual limit
Subject to overall annual limit
Subject to overall annual limit
Carotid stents R15 750 R15 750 R15 750 R15 750 R15 750 R15 750
Renal stents R5 250 R5 250 R5 250 R5 250 R5 250 R5 250
Aneurysm coils R36 750 R36 750 R36 750 R36 750 R35 175 R34 125
2.3 Heart valves etc. (subject to overall limit) Heart valves (Mitral etc) ANNUAL R23 100 R23 100 R23 100 R23 100 R23 100 R23 100
2.4 Orthopaedic prosthesis(subject to overall limit)
Hip prosthesis ANNUAL R33 500 R33 500 R33 500 R31 000 R30 000 R29 000
Knee prosthesis ANNUAL R33 500 R33 500 R33 500 R31 000 R30 000 R29 000
Shoulder prosthesis ANNUAL R33 500 R33 500 R33 500 R31 000 R30 000 R29 000
Elbow prosthesis ANNUAL R33 500 R33 500 R33 500 R31 000 R30 000 R29 000
Ankle prosthesis ANNUAL R33 500 R33 500 R33 500 R31 000 R30 000 R29 000
Wrist prosthesis ANNUAL R33 500 R33 500 R33 500 R31 000 R30 000 R29 000
Finger prosthesis ANNUAL R21 000 R21 000 R21 000 R21 000 R21 000 R21 000
Spinal instrumentation – per level limited to 2 levels
and 1 procedure perbeneficiary per year
ANNUAL R23 100 R20 000 R18 000 R15 000 R10 000 R10 000
Spinal cages ANNUAL R11 550 R10 000 R9 000 R8 000 R7 500 R7 500
Spinal implantable devices ANNUAL R27 620 R25 000 R20 000 R15 000 R12 000 R12 000
Internal fixators for fractures ANNUAL R26 250 R25 000 R20 000 R18 000 R15 000 R15 000
/ Member Scheme Benefit Options / CompCare Wellness Medical Scheme / 2019 PAGE 18
SUB-LIMITS FOR SURGICAL PROSTHESIS, ELECTRONIC AND NUCLEAR DEVICES AND APPLIANCES: 2019 (continued)
SURGICAL INTERNAL PROSTHESIS DESCRIPTION FREQUENCY PINNACLE DYNAMIX SYMMETRY MUMED UNISAVE AXIS
2.5 Artificial limbs (subject to overall limit)
Through knee ANNUAL R46 960 R40 000 R35 200 R30 000 R20 000 R20 000
Below knee ANNUAL R39 900 R35 000 R30 000 R25 000 R20 000 R20 000
Above knee ANNUAL R46 200 R40 000 R35 000 R30 000 R20 000 R20 000
Partial foot ANNUAL R19 950 R15 000 R12 000 R10 000 R8 000 R8 000
Partial hand ANNUAL R12 600 R10 000 R10 000 R9 000 R8 000 R8 000
Below elbow ANNUAL R36 750 R35 000 R30 000 R25 000 R20 000 R20 000
Above elbow ANNUAL R42 000 R40 000 R35 000 R30 000 R20 000 R20 000
2.6 Other prosthesis (subject to overall limit)
Intra ocular lenses ANNUAL R4 200 R3 500 R3 000 R2 700 R2 500 R2 500
Bladder sling ANNUAL R8 000 R8 000 R8 000 R8 000 R8 000 R8 000
Hernia mesh ANNUAL R8 400 R8 400 R8 400 R8 400 R8 400 R8 400
Vascular grafts ANNUAL R27 075 R27 075 R25 000 R20 000 R15 000 R15 000
2.7 Electronic and nuclear devices (Subject to PMBs)
Internal cardiac defibrillator ANNUAL Subject to overall annual limit
Subject to overall annual limit
Subject to overall annual limit
Subject to overall annual limit
Subject to overall annual limit
Subject to overall annual limit
Single chamber pacemaker ANNUAL Subject to overall annual limit
Subject to overall annual limit
Subject to overall annual limit
Subject to overall annual limit
Subject to overall annual limit
Subject to overall annual limit
Dual chamber pacemaker ANNUAL Subject to overall annual limit
Subject to overall annual limit
Subject to overall annual limit
Subject to overall annual limit
Subject to overall annual limit
Subject to overall annual limit
Internal nerve stimulators ANNUAL R112 000 R112 000 EXCLUDED EXCLUDED EXCLUDED EXCLUDED
Cochlear implants and Bone Anchored Hearing Aids (BAHA) ANNUAL R195 000 R195 000 EXCLUDED EXCLUDED EXCLUDED EXCLUDED
Insulin pumps ANNUAL R23 100 R23 100 EXCLUDED EXCLUDED EXCLUDED EXCLUDED
/ Member Scheme Benefit Options / CompCare Wellness Medical Scheme / 2019PAGE 19
SUB-LIMITS 2019 (continued)
SURGICAL INTERNAL PROSTHESIS DESCRIPTION FREQUENCY PINNACLE DYNAMIX SYMMETRY MUMED UNISAVE AXIS
2.8 Surgical appliances(subject to day-to-day benefits)
Overall limit ANNUAL R32 320 R16 570 R11 600 R10 500 R8 840
PMBs only
Hearing aids 1 per year, 3 yearly interval R22 100 R16 570 R10 000 R8 000 R5 000
Artificial eyes 5 year interval R22 100 R16 570 R11 600 R10 500 R8 840
BP monitor 3 year interval R665 R665 R665 R665 R665
Glucometer 3 year interval R665 R665 R665 R665 R665
Humidifier 3 year interval R275 R275 R275 R275 R275
Nebuliser 3 year interval R550 R550 R550 R550 R550
Moonboot Annual R2 210 R2 210 R2 210 R2 210 R2 210
Elbow crutches Annual R665 R665 R665 R665 R665
CPAP machines 3 year interval R9 945 R9 945 EXCLUDED EXCLUDED EXCLUDED
Apnoea monitors forinfants < 1yr
Once per beneficiary per lifetime
R9 725 R9 725 R9 725 EXCLUDED Subject to Savings
Braces and callipers Annual R720 R720 R720 R720 R720
Rigid back brace Annual R5 525 R5 525 R3 000 EXCLUDED EXCLUDED
Sling clavicle brace Annual R525 R525 R525 EXCLUDED EXCLUDED
Wigs Annual R1 990 R1 990 R1 990 EXCLUDED EXCLUDED
Bra’s for breast prosthesis after mastectomies 2 per annum R2 760 R2 760 R2 760 R1 000 R1 000
Breast prosthesis Annual R3 315 R3 315 R3 315 R1 000 R1 000
Commodes 3 year interval R2 105 R2 105 R2 105 R1 000 R1 000
Wheelchairs 3 year interval R4 420 R4 420 R4 420 R1 000 R1 000
Walking frames Annual R665 R665 R665 EXCLUDED EXCLUDED
Rehabilitative foot orthotics Annual R3 315 R3 315 R2 000 R1 000 R1 000
2.9 Wearable devices Wearable devices claimable only with a valid NAPPI code Annual
Available savings up to a maximum of R3 000
Available savings up to a maximum of R3 000
Available savings up to a maximum of R3 000
EXCLUDE
Available savings up to a maximum of R3 000
2.10 Stockings
Elastic stockings 2 pairs per annum R1 050 R1 050 R750 R500 R500
Full length stockings 2 pairs per annum R1 050 R1 050 R800 R500 R500
Anti-embolic stockings Annual R1 105 R1 105 R500 R500 R500
EXCLUDE
PMBs only
/ Member Scheme Benefit Options / CompCare Wellness Medical Scheme / 2019 PAGE 20
CHRONIC CONDITIONS COVERED: EFFECTIVE 1 JANUARY 2019
(*PMB) PINNACLE DYNAMIX SYMMETRY MUMED UNISAVE AXIS NETWORX
Addison’s disease * Yes Yes Yes Yes Yes Yes Yes
Allergic rhinitis Yes Yes No No No No No
Angina Yes Yes Yes Yes No No No
Ankylosing spondylitis Yes Yes No Yes No No No
Anorexia nervosa Yes No No No No No No
Asthma * Yes Yes Yes Yes Yes Yes Yes
Attention deficit disorder Yes Yes Yes No No No No
Barrett’s oesophagitis Yes No No No No No No
Bechet’s disease Yes Yes No No No No No
Benign prostatic hyperplasia Yes No No No No No No
Bipolar mood disorder* Yes Yes Yes Yes Yes Yes Yes
Bronchiectasis * Yes Yes Yes Yes Yes Yes Yes
Bulimia nervosa Yes No No No No No No
Cardiac arrhythmias * Yes Yes Yes Yes Yes Yes Yes
Cardiomyopathy * Yes Yes Yes Yes Yes Yes Yes
Chronic renal failure * Yes Yes Yes Yes Yes Yes Yes
Congestive cardiac failure * Yes Yes Yes Yes Yes Yes Yes
Conn’s syndrome Yes No No No No No No
Chronic obstructive pulmonary disease * Yes Yes Yes Yes Yes Yes Yes
Chronic bronchitis Yes Yes Yes Yes No No No
Connective tissue disorders (mixed) Yes Yes No No No No No
Coronary artery disease * Yes Yes Yes Yes Yes Yes Yes
Crohn’s disease * Yes Yes Yes Yes Yes Yes Yes
Cushing’s syndrome Yes Yes Yes No No No No
Cystic fibrosis Yes Yes No No No No No
Deep vein thrombosis Yes No No No No No No
Diabetes insipidus * Yes Yes Yes Yes Yes Yes Yes
Diabetes mellitus type 1 and 2 * Yes Yes Yes Yes Yes Yes Yes
Emphysema Yes Yes Yes Yes No No No
/ Member Scheme Benefit Options / CompCare Wellness Medical Scheme / 2019PAGE 21
(*PMB) PINNACLE DYNAMIX SYMMETRY MUMED UNISAVE AXIS NETWORX
Epilepsy * Yes Yes Yes Yes Yes Yes Yes
Generalised anxiety disorder Yes Yes No No No No No
Glaucoma * Yes Yes Yes Yes Yes Yes Yes
Gastro-oesophageal reflux disease Yes Yes No No No No No
Gout/hyperuricemia Yes Yes No No No No No
Haemophilia * Yes Yes Yes Yes Yes Yes Yes
HIV/AIDS * Yes Yes Yes Yes Yes Yes Yes
Hormone replacement therapy Yes Yes Yes Yes No No No
Huntington’s disease Yes Yes No No No No No
Hypercholesterolemia/hyperlipidaemia * Yes Yes Yes Yes Yes Yes Yes
Hypertension * Yes Yes Yes Yes Yes Yes Yes
Hypoparathyroidism Yes Yes Yes Yes No No No
Hypothyroidism * Yes Yes Yes Yes Yes Yes Yes
Ischaemic heart disease Yes Yes Yes Yes No No No
Motor neuron disease Yes Yes No No No No No
Multiple sclerosis * Yes Yes Yes Yes Yes Yes Yes
Muscular dystrophy Yes Yes Yes No No No No
Myasthenia gravis Yes Yes Yes Yes No No No
Narcolepsy Yes No No No No No No
Obsessive compulsive disorder Yes Yes No No No No No
Osteoarthritis Yes No No No No No No
Osteoporosis Yes Yes No No No No No
CHRONIC CONDITIONS COVERED: EFFECTIVE 1 JANUARY 2019 (continued)
/ Member Scheme Benefit Options / CompCare Wellness Medical Scheme / 2019 PAGE 22
CHRONIC CONDITIONS COVERED: EFFECTIVE 1 JANUARY 2019 (continued)
(*PMB) PINNACLE DYNAMIX SYMMETRY MUMED UNISAVE AXIS NETWORX
Paget’s Disease of the Bone Yes Yes Yes No No No No
Panic disorder Yes Yes No No No No No
Paraplegia/quadriplegia Yes Yes Yes No No No No
Parkinson’s disease * Yes Yes Yes Yes Yes Yes Yes
Pemphigus Yes Yes Yes No No No No
Peripheral Arteriosclerotic disease Yes Yes No No No No No
Polyarthritis nodosa Yes Yes Yes No No No No
Post-traumatic stress syndrome Yes Yes Yes No No No No
Psoriasis/psoriatic arthritis Yes No No No No No No
Pulmonary interstitial fibrosis Yes Yes Yes No No No No
Rheumatoid arthritis * Yes Yes Yes Yes Yes Yes Yes
Schizophrenia * Yes Yes Yes Yes Yes Yes Yes
Scleroderma (systemic sclerosis) Yes Yes No No No No No
Stroke Yes Yes Yes Yes No No No
Systemic lupus erythematosus * Yes Yes Yes Yes Yes Yes Yes
Thrombocytopenic purpura Yes Yes No No No No No
Ulcerative colitis * Yes Yes Yes Yes Yes Yes Yes
Unipolar mood disorder/major depression Yes Yes Yes No No No No
Valvular heart disease Yes Yes Yes No No No No
Vertigo Yes Yes Yes Yes No No No
Zollinger-Ellison syndrome Yes Yes No No No No No
Total conditions covered 73 64 47 37 27 27 27
/ Member Scheme Benefit Options / CompCare Wellness Medical Scheme / 2019PAGE 23
EXCLUSIONS AND LIMITATIONS
Exclusions
The scheme will pay in full, without co-payment or use of deductibles, the diagnosis, treatment and care costs of the Prescribed Minimum Benefits (PMBs) as per regulation 8 of the Medical Schemes Act. Furthermore, where a protocol or a formulary drug preferred by the scheme has been ineffective or would cause harm to a beneficiary, the scheme will fund the cost of the appropriate substitution treatment without a penalty to the beneficiary as required by regulation 15H and 15I of the Medical Schemes Act.
The following exclusions will apply to a member and/or his/her dependants, unless the particular exclusion is covered under the statutory PMBs:
1. Unless otherwise provided for or decided by the Board of Trustees, expenses incurred in connection with any of the following will not be paid by the scheme:
1.1 All costs that are more than the annual maximum benefit to which a member is entitled in terms of the rules of the scheme.
1.2 Subject to rule 8.4.1 of the main constitution, a general waiting period of 3 months will apply to a member and his dependants from the date of joining the scheme.
1.3 Subject to rule 8.4.2 of the main constitution, a condition specific waiting period of not more than 12 months in respect of pre-existing sickness conditions will apply to a member and his dependants from the date of joining the scheme.
1.4 All costs incurred during waiting periods and for conditions will not be disclosed.
1.5 Professional fees and expenses incurred by healthcare professionals:
• After hours consultations according to member’s choice.• Appointments not honoured by beneficiaries.• Charges for interest by health care providers, if due to member
negligence.• Costs incurred for insurance medical purposes.• Fees for medical reports and motivations by any service provider,
unless required by the scheme.• Discretionary conditions and services with hospital admissions not
authorised.• Telephonic consultations with healthcare providers.
1.6 Costs for services rendered by:
1.6.1 Persons not registered with a recognised professional body constituted in terms of an Act of Parliament of the Republic of
South Africa; or
1.6.2 Any institution, nursing home or similar institution except a state or provincial hospital not registered in terms of any law of the
Republic of South Africa.
1.7 Frail Care - accommodation and nursing services rendered in convalescent or old age homes or similar institutions catering for the aged or chronically ill.
1.8 Holidays for recuperative purposes, whether deemed medically necessary or not.
1.9 All costs for rehabilitation for any particular sickness or condition, except for PMBs.
1.10 Private nursing fees in respect of both mother and child in postpartum cases.
1.11 Cosmetic procedures (Unless a PMB):
• All costs for cosmetic procedures / treatment / medication, except if as a result of an accident, illness or disease.
• The costs of breast reduction and enlargement operations are excluded, except in the case of a breast reconstruction after a radical mastectomy.
• Abdominal lipectomy.• Face lift.• Genioplasty.• Blepharoplasty.• Hair removal or implants.• Periodontal plastic procedures for cosmetic purposes.• Removal of scars, tattoos by salabrasion, chemosurgery or any
such skin abrasion.• Removal of skin blemishes, port wine stains (vascular birthmark).• Surgery related to transsexual procedures.• Otoplasty for bat ears.• Nasal reconstruction, including septoplasties, osteotomies and
nasal tip surgery.• Sclerotherapy are subject to medical specialist motivation.
1.12 Dental procedures and treatments:
• Dental extractions for non-medical purposes.• Bleaching of teeth that have not been root canal treated.• High impact acrylic dentures.• The cost of the use of gold in dentures.• Discretionary procedures – elective treatments and surgery for
personal reasons and not directly caused and related to illness, accident or disease.
1.13 The treatment of artificial insemination of a person as defined in the Human Tissues Act, 1983 (Act 65 of 1983) except for PMBs.
1.14 In respect of infertility (PMB Code 902M), the following services are excluded:• Assisted reproductive technology (ART) techniques including in-
vitro fertilisation (IVF).• Gamete intrafallopian tube transfer (GIFT).• Zygote intrafallopian transfer (ZIFT).• Intracytoplasmic sperm injection (ICSI).
1.15 Circumcision, except in phimosis or evidence-based medical indications. Female oral contraceptives will not be covered from the Hospital Benefit, but may be claimed from savings or day-to-day risk benefits where applicable or available. Any other contraceptive devices or measures will not be covered.
1.16 Reversal of vasectomies or tubal ligation (sterilisation). Vasectomies and tubal ligation (sterilisation) are covered from the Hospital Benefits.
1.17 All costs related to the treatment, medication or surgical procedures of obesity, including bariatric surgery, gastric stapling, wring of the jaw for weight loss purposes etc.
1.18 All costs relating to a treatment if the efficacy and safety of such treatment cannot be proved.
1.19 The purchase of:
• Patent medicines and proprietary preparations • Applicators, toiletries and beauty preparations • Bandages, cotton wool and other consumable items • Patented foods, including baby foods (Unless a PMB) • Tonics, slimming preparations and drugs as advertised to the
public • Household and biochemical remedies • Contraceptives, unless specifically provided for in the Medicine
Formulary applicable to each respective medical scheme option and
• Vitamins and minerals; (Unless a PMB) • Nutritional supplements and baby foods/milk substitutes • Anabolic steroids • Sunscreen agents • Skin lightening treatments • Sun glasses
1.20 Medication not registered by the Medicine Control Council, unless otherwise specified, e.g. homeopathic medicines which are covered in certain medical scheme options and subject to limits.
1.21 Travelling expenses incurred by members, excluding benefits covered by Emergency Medical Services in the event of an emergency medical condition.
1.22 All costs, which in the opinion of the Medical Advisor are not medically necessary or appropriate to meet the healthcare needs of the patient.
/ Member Scheme Benefit Options / CompCare Wellness Medical Scheme / 2019 PAGE 24
EXCLUSIONS AND LIMITATIONS (continued)
1.23 Medical examinations or inoculations initiated by the employer.
1.24 The utilisation of certain specialised technologies to perform a procedure, where an alternative, more cost effective method of performing the procedure is excluded unless prior clinical motivation from the attending specialist practitioner is obtained more than 7 working days in advance, and subject to approval by the Medical Advisor of the medical scheme. If authorised a co-payment of R5 000 will be levied.
1.25 Alternative and / or complementary health services that are not supported by evidence based medicine are excluded:
• Acupuncture• Aromatherapy• Ayurvedics• Chelation therapy• Colonic irrigation • Iridology• Masseurs• Osteopathy• Phytotherapy• Reflexology• Traditional medicine
1.26 Certain conditions relating to educational and / or psychological performance and / or behaviour, except for the PMBs:
• Behavioural problems.• Concentration / learning / reading problems.• Co-ordination abnormalities.• Delayed speech development.• Dyslexia.• Sexual disorders.• Career guidance.• Marriage counselling.
1.27 Costs incurred for surrogate parenting.
1.28 Products, devices and appliances:
• Gum guards for sport purposes. • Oral appliances specified for the treatment of headaches.• APS / Tense Therapy Machines.• Back rest and / or seats.• Contact lens solutions.• Chair seats, excluding wheelchair seats.• Cushions.• Disposable nappies.• Face creams.• Health shoes.• Klaasvakie mattresses, mattresses or pillows.• Linen savers and / or protectors and /or waterproof sheets.• Prescription and non-prescription sunglasses.
• Protective gear.• Sheep skins.• Shoe inserts.• Shower and bath rails.
1.29 All healthcare costs relating to medical procedures, prostheses or practices that may be new or deemed to be experimental, with insufficient evidence based outcomes are excluded.
2. Limitation Of Benefits
2.1 The maximum benefits to which a member and his dependants are entitled in any financial year are limited as set out in Annexure B.
2.2 Members admitted during the course of a financial year are entitled to the benefits set out in the third column of Annexure B, with the maximum benefits being adjusted in proportion to the period of membership calculated from the date of admission to the end of that particular financial year.
Unless otherwise decided by the Board of Trustees, benefits in respect of medicines obtained on a prescription are limited to one month’s supply for every such prescription or repeat thereof.
3. Benefits Excluded Insofar As These Are Not Prescribed Under The PMB Benefits
3.1 Medicine and injection material
3.1.1 The following medicine, unless they form part of the public sector protocols and are authorised by the relevant managed healthcare programme:
Any specialised drugs as defined by the managed care company (e.g. biological, tyrosine kinase inhibitors) that have not convincingly demonstrated a median overall survival advantage of more than 3 (three) months in locally advanced or metastatic solid organ malignant tumours, unless deemed cost effective for the specific setting, compared to standard therapy (excluding specialised drugs) as defined in established and generally accepted treatment protocols, for example sorafenib for hepatocellular carcinoma, bevacizumab for colorectal and metastatic breast cancer.
The scheme reserves the right to decline payment for any new medical technology, or investigational procedures, interventions, new drugs or medicines as applied in clinical medicine, including new indications for existing medicines or technologies unless they have demonstrated:
• Evidence based efficacy in clinical medicine.• Affordability by the scheme.
3.1.2. Admission to hospital for the purposes of administering treatments which may be provided in a doctor’s rooms.
3.1.3 Axis and Axis ED Options (hospital plan)
Admission to hospital for the administration of drugs or medicines, excluding / unrelated to chemotherapy, which may be administered to a patient as an outpatient in the doctor rooms e.g. Aredia® infusions. Aclasta® injections, Avastin® injections etc.
/ Member Scheme Benefit Options / CompCare Wellness Medical Scheme / 2019PAGE 25
CONTRIBUTIONS PER OPTION EFFECTIVE 1 JANUARY 2019 (all values in Rand unless otherwise specified)
PINNACLE Principal Member Adult Dependant Child Dependant
Risk 5 208 4 055 1 442Savings 1 221 950 338Total 6 429 5 005 1 780Annual Savings 14 652 11 400 4 056AFB 3 857 3 003 1 068Total Day-to-day 18 509 14 403 5 124Annual Threshold 21 399 16 413 5 698SPG 2 890 2 010 574
DYNAMIX Principal Member Adult Dependant Child Dependant
Risk 4 169 3 256 1 163Savings 678 529 189Total 4 847 3 785 1 352Annual Savings 8 136 6 348 2 268AFB 2 908 2 271 811Total Day-to-day 11 044 8 619 3 079Annual Threshold 17 197 13 191 4 675SPG 6 153 4 572 1 596
SYMMETRY Principal Member Adult Dependant Child Dependant
Risk 3 448 2 689 973Savings 383 298 108Total 3 831 2 987 1 081Savings 4 596 3 576 1 296AFB 4 385 3 402 1 210Total Day-to-day 8 981 6 978 2 506
MUMED Principal Member Adult Dependant Child Dependant
Risk 3 046 2 374 857AFB 5 940 3 720 1 480
UNISAVE Principal Member Adult Dependant Child Dependant
Risk 1 781 1 518 534Savings 593 506 178Total 2 374 2 024 712Annual Savings 7 116 6 072 2 136
AXIS Principal Member Adult Dependant Child Dependant
Contribution 1 794 1 794 554
NETWORX (Network Private Hospitals) Principal Member Adult Dependant Child Dependant
0-500 404 404 404501 - 4 000 1 035 983 3634 001 – 5 000 1 035 983 3635 001 – 6 000 1 035 983 3636 001 - 8 000 1 088 1 035 3828 001 - 9 000 1 233 1 174 4359 001-10 000 1 312 1 246 46210 000+ 2 413 2 169 844
/ Member Scheme Benefit Options / CompCare Wellness Medical Scheme / 2019 PAGE 26
CONTRIBUTIONS PER OPTION EFFECTIVE 1 JANUARY 2019 (continued)
DYNAMIX ED Principal Member Adult Dependant Child Dependant
Risk 3 431 2 677 971Savings 558 435 157Total 3 989 3 112 1 128Annual Savings 6 696 5 220 1 884AFB 2 393 1 867 677Total Day-to-day 9 089 7 087 2 561Annual Threshold 15 242 11 659 4 157SPG 6 153 4 572 1 596
SYMMETRY ED Principal Member Adult Dependant Child Dependant
Risk 2 814 2 190 790Savings 312 243 87Total 3 126 2 433 877Savings 3 744 2 916 1 044AFB 3 604 2 797 983Total Day-to-day 7 348 5 713 2 027
MUMED ED Principal Member Adult Dependant Child Dependant
Risk 2 473 1 925 686AFB 5 740 3 590 1 430
AXIS ED Principal Member Adult Dependant Child Dependant
Contribution 1 517 1 517 475
NETWORX ED Principal Member Adult Dependant Child Dependant
0-500 343 336 185501-4 000 495 488 2444 001-5 000 633 607 3035 001-6 000 633 607 3036 001-8 000 758 719 3638 001-9 000 758 719 3639 001-10 000 804 765 38210 000+ 1 583 1 424 706
PINNACLE ED Principal Member Adult Dependant Child Dependant
Risk 4 353 3 387 1 213Savings 1 021 794 284Total 5 374 4 181 1 497Annual Savings 12 252 9 528 3 408AFB 3 224 2 509 898Total Day to day 15 476 12 037 4 306Annual Threshold 18 366 14 047 4 880SPG 2 890 2 010 574
/ Member Scheme Benefit Options / CompCare Wellness Medical Scheme / 2019PAGE 27
CompCare offers members a number of Managed Care initiatives, which are all designed to ensure that members receive quality healthcare at an affordable cost. These are:
MANAGED CARE INITIATIVES
1. Chronic medication pre-authorisation Members are required to register chronic medication prescriptions with Universal to receive the chronic
medication benefit. To register your chronic medication prescription with Universal, you, your doctor or your pharmacist need to contact Universal or send an e-mail. Application forms are no longer required.
2. Hospital utilisation management Universal Care offers a complete hospital utilisation management service. It is the member’s responsibility to
ensure that all non-emergency hospital admissions are authorised.
These must be authorised at least 48 hours prior to admission. The member, doctor or hospital may phone in for this authorisation. A penalty will apply for late requests for authorisations.
Emergency admissions must be authorised on the first working day after admission. There will be a penalty if the member does not obtain authorisation. This service also applies to oncology treatment.
3. Disease management Universal Care offers a comprehensive disease management service, including HIV/AIDS counselling. This service
is designed to empower members to manage their chronic conditions more effectively.
Members are provided with telephonic counselling, e-mail information, as well as on-line health and wellness information. This information can be communicated to the patient via: the disease management Call Centre, website, e-mail, fax, post and physical handout point.
All CompCare members and their dependants diagnosed with a chronic condition such as HIV/AIDS, asthma, diabetes, hypertension etc., should register on the Disease Management Programme. By registering, an individual will have access to personalised health and wellness information. Members are also invited to phone the disease management Call Centre should they wish to speak to a nurse counsellor.
4. Pathology management Universal Care provides a service that ensures that the standard pathology guidelines are followed.
5. Specialised dentistry management Universal Care offers a pre-authorisation service for all specialised dentistry. Prior to having specialised dentistry
the member is required to obtain pre-authorisation.
6. Trauma expense recovery Universal Care offers a service where medical expenses that are the liability of a third party are recovered for
CompCare. In most cases these recoveries refer to road accidents where a third party was involved.
7. Emergency evacuation Netcare 911 offers an emergency evacuation service that will transport members to the nearest hospital for
treatment. Members have access to this benefit in and outside of the borders of South Africa (worldwide).
8. Medical advice, information and assistance Netcare 911 personnel, including paramedics, nurses and doctors are available 24 hours a day to provide general
medical information and advice. This is an advisory service as a telephone conversation does not permit an accurate diagnosis.
In addition to general medical advice, Netcare medical operators can also guide you through a medical crisis situation, provide emergency advice and organise for you to receive the support you need.
9. Fraud detection Fraud is a major problem in South Africa and the healthcare arena is no exception. CompCare has been very
successful in containing fraud by making use of a system of member and practitioner profiling and forwarding this information to a private investigation unit.
CompCare is committed to conducting healthy business practices with honesty and integrity, which ensures the continued and future success of the Scheme.
Fraud presents increasing challenges in our country. Too often, it is undetected and goes unreported, resulting in financial losses for schemes which eventually leads to the detriment of all members. CompCare is no different and have subscribed to a service that will enable all members to report fraud and other crime anonymously.
This service involves a Fraud Hotline, independently and anonymously managed by an external firm, Vuvuzela Hotline. Confidentiality and anonymity are guaranteed, and therefore, no member reporting suspected fraudulent activity will ever be identified.
What can be reported?Toll free number: 080 111 4447Fax: 086 672 1681E-mail: universal@thehotline.co.zaWebsite: www.thehotline.co.zaWebApp: www.thehotlineapp.co.zaCallback No (please call me’s) 072 595 9139
How does it work? Anyone can report their suspicion(s) through the Vuvuzela Hotline, using the following means of communication:
• Fraud • Procurement irregularities• Corruption • Bribery• Unethical behaviour • Maladministration • Misuse of funds
This is a 24/7/365 Fraud Hotline. The Vuvuzela Hotline is part of CompCare’s commitment to zero tolerance for dishonest and unethical behaviour.
/ Member Scheme Benefit Options / CompCare Wellness Medical Scheme / 2019 PAGE 28
CONTACT DETAILS
Division Contact company Contact number Fax number E-mail address Postal address Website
Call Centre Universal Healthcare Administrators (Pty) Ltd 0861 222 777 0866 450 991
correspondence@universal.co.za
claims@universal.co.zaPrivate Bag X49, Rivonia, 2128 www.compcare.co.za
Membership Universal Healthcare Administrators (Pty) Ltd 0861 222 777 0862 106 635 membership@universal.co.za Private Bag X49, Rivonia, 2128 www.compcare.co.za
Contributions Universal Healthcare Administrators (Pty) Ltd 0861 222 777 0865 057 882 billings@universal.co.za Private Bag X49, Rivonia, 2128 www.compcare.co.za
Hospital pre-authorisation Universal Care (Pty) LtdPre-authorisation
0860 111 0900862 957 355 preauthorisation@universal.co.za Private Bag X49, Rivonia, 2128 www.universal.co.za
Hospital account queries Universal Care (Pty) LtdHospital account enquiries
011 208 11000862 957 356 hospitalaccounts@universal.co.za Private Bag X49, Rivonia, 2128 www.universal.co.za
Disease management Universal Care (Pty) Ltd0861 222 777
0860 111 9000862 957 305 diseasemanagement@universal.co.za Private Bag X49, Rivonia, 2128 www.universal.co.za
Maternity management Universal Care (Pty) Ltd0861 222 777
0860 111 0900862 957 355 correspondence@universal.co.za Private Bag X49, Rivonia, 2128 www.universal.co.za
HIV/AIDS management Universal Care (Pty) Ltd0861 222 777
0860 111 9000862 957 305 diseasemanagement@universal.co.za Private Bag X49, Rivonia, 2128 www.universal.co.za
Oncology management Universal Care (Pty) Ltd0861 222 777
0860 111 0900862 957 307 oncology@universal.co.za Private Bag X49, Rivonia, 2128 www.universal.co.za
Trauma expense recovery (MVA) Universal Care (Pty) Ltd 0861 208 1167/68 0865 768 702 trauma@universal.co.za Private Bag X49, Rivonia, 2128 www.universal.co.za
Universal 360° Universal 360° 086 155 LIVE (5483) 0865 041 545 360@universal.co.za Private Bag X49, Rivonia, 2128 www.universal360.co.za
Ambulance Netcare 911 082 911
Medicine management Universal Care (Pty) Ltd 0860 111 900 0862 108 743 chronicmedicine@universal.co.za Private Bag X49, Rivonia, 2128 www.universal.co.za
/ Member Scheme Benefit Options / CompCare Wellness Medical Scheme / 2019PAGE 29
MEMBER GUIDE
1. Rules of the scheme
The scheme is governed by a set of rules submitted to and approved by the Registrar for Medical schemes. All terms and conditions are set out in detail in the rules of the scheme, which can be viewed at the office of the administrator. The rules of the scheme always apply during a dispute resolution.
2. Membership
Who is eligible for membership?Membership is open to any individual or company/group, except where the member ceases to be a permanent resident in the Republic of South Africa.
The scheme provides cover for all international students while studying in the Republic of South Africa.
2.1 Who can be registered as dependants?• A member‘s spouse or partner – a person with whom the member is legally married, or has a two year or longer
committed relationship akin to marriage, based on objective criteria of mutual dependency and a shared common household, married in terms of any law or traditional/customary marriage (marriage certificate/affidavit/suitable other certificate required).
• Surviving spouse members – continuation of a surviving spouse of the main member is allowed to continue on the medical aid, provided that they were registered at the time of the main member’s death (marriage and death certificate required).
• A child under the age of 27 – is not in receipt of a regular remuneration of more than the maximum social pension per month, or a child of any age due to being mentally or physically challenged, is a dependent of the member, or legally adopted child/children placed in your care and custody by virtue of a court order (legal proof required).
• Full time student – Proof of registration of current year is required from a secondary or recognised tertiary institution and each year thereafter, in order for the dependant to qualify at child rates, to a maximum of up to 27 years, thereafter Committee approval is required each year.
• Part time students – an affidavit is required, stating that the child is unemployed and financially dependent on the principal member. Proof of registration as a student is required from the recognised institution. The dependant will be billed at adult rates.
• Unemployed child – (up to a maximum age of 27) who is unemployed and financially dependent on the principal member, (affidavit required).
• Disabled / mentally challenged – full medical report required upon application in order to qualify at child dependant rates.
2.2 How are waiting periods applied?Prospective members are required to disclose all details in full of any sickness or medical condition for which medical advice, diagnosis, care or treatment was recommended and/or received prior to the twelve months period ending on the date of which application is made.
Waiting periods are applied when members join the scheme or are registered as dependants according to the following instances:
• If you have never been a member/dependant or not covered on a medical scheme for a period of more than 90 days immediately before applying to the scheme, the scheme may impose a general waiting period of three months and twelve months condition specific waiting on any /all pre-existing medical conditions. This will also be applicable to Prescribed Minimum Benefits.
• If you have been on a medical scheme for a period of less than 24 months and you apply for membership within the three months of termination from the previous medical scheme, a condition specific waiting period for twelve months will apply. If the beneficiary suffers from any pre-existing condition, the scheme may impose any unexpired balances by the previous scheme. The beneficiary will be entitled to the Prescribed Minimum Benefits.
• If you have been on a medical scheme for a period of more than 24 months and apply for membership within the three-month period from termination from the previous medical scheme, the general waiting period of three months will apply. You will be entitled to the Prescribed Minimum Benefits.
When does the benefit year start?The scheme’s benefits year begins as at 1 January and ends as at 31 December of that year. This means that if you join the scheme on 1 January you are entitled to the full allocation of the year’s benefits and limits. However, if you join the scheme during the benefit year, you are only entitled to pro-rated benefits and limits, meaning that you are only entitled to a time-appropriate proportion of the benefits and limits.
Please note: You have the opportunity to review and change your choice of plan, three months prior to the beginning of each benefit year. Once you have selected a plan for the benefit year, you cannot change your plan during that benefit year.
2.3 Proof of membership Every member shall be furnished with a membership card. You will be required to exhibit this membership card when visiting a healthcare service provider and/or should be admitted to a hospital. You therefore need to ensure that your card is kept secure at all times in order to prove membership.
2.4 How do I go about changing my details?Complete a Member Update Information form, available from our offices on 0861 222 777, or obtainable from our website (www.compcare.co.za). A member must notify the scheme within 30 days of any change of address, including the domicilium citandi et executandi (address at which legal proceedings maybe instituted).
The scheme shall not be held liable if a member’s rights are prejudices or forfeited as a result of the member neglecting to comply with the requirements of this rule.
2.5 Late joiner penaltiesLate joiner penalties are applicable to an applicant or adult dependant of an applicant, who at the date of application for membership or admission as a dependant is older than the age of 35 years, depending on the number of years that they have not belonged to a registered South African medical scheme. This excludes beneficiaries who enjoyed coverage with one or more medical schemes as from the date proceeding, 1 April 2001, without a break in coverage exceeding three consecutive months since the 1 April 2001. Penalties shall be applied only to that portion of the contribution relative to the late joiner and shall not exceed the following bands:
Penalty bands Maximum penalty
1 - 4 years 0.05 x contribution
5 - 14 years 0.25 x contribution
15 - 24 years 0.50 x contribution
25 + years 0.75 x contribution
The penalty is calculated as per the following formulas: A = B (35+ C)
Where : A = number of years in the penalty band column, B = age of the applicant at the time of application,C = the number of years of creditable coverage
2.6 Complaints and disputes:Members may lodge their complaints telephonically, or in writing, to the scheme. The scheme’s dedicated telephone number for dealing with telephonic complaints is 0861 222 777.
Call Centre agents will assist the member immediately if possible. All unresolved telephonic complaints or complaints received in writing will be responded to by the scheme in writing within 30 days of receipt thereof. Any dispute, which may arise between a member, prospective member, former member or a person claiming by virtue of such member and the scheme or an officer of the scheme, must be referred by the principal officer to a disputes committee (appointed by the Board of Trustees) for adjudication.
/ Member Scheme Benefit Options / CompCare Wellness Medical Scheme / 2019 PAGE 30
MEMBER GUIDE (continued)
On receipt of a request in terms of this rule, the principal officer must convene a meeting of the disputes committee by giving not less than 21 days notice in writing to the complainant and all the members of the disputes committee, stating the date, time and venue of the meeting and particulars of the dispute.
The disputes committee may determine the procedure to be followed. The parties to any dispute have the right to be heard at the proceedings, either in person or through a representative.
An aggrieved person has the right to appeal to the Council for Medical Schemes against the decision of the disputes committee. Such appeal must be in the form of an affidavit and directed to Council and shall be furnished to the Registrar not later than three months after the date on which the decision concerned was made. See page 23 for contact details.
3. Contributions payable
The total monthly contributions payable to the scheme by or in respect of a member are as stipulated in the contribution tables in the scheme rules. It shall be the responsibility of the member to notify the scheme of changes in income that may necessitate a change in contribution. Contributions shall be due monthly in arrears or advance, as stipulated in the rules and payable by not later than the third day of each month.
Where contributions or any other debt owing to the scheme have not been paid within three days of the due date, the scheme shall have the right to suspend all benefit payments in respect of claims which arose during the period of default. In the event that payments are brought up to date, and provided membership has not been cancelled, benefits shall be reinstated without any break in continuity subject to the right of the scheme to levy a reasonable fee to cover any expenses associated with the default and to recover interest on the arrear amount at the prime overdraft rate of the scheme’s bankers. If such payments are not brought up to date, no benefits shall be due to the member from the date of default and any such benefit paid will be recovered by the scheme.
3.1 SavingsYour total annual savings contributions are advanced at the beginning of the benefit year (Jan to Dec) for the full calendar year (Jan to Dec). Termination of membership during the benefit year will result in savings being pro-rated. This pro-ration could result in savings contributions being owed to the scheme. Should you terminate your membership with the scheme, the savings balance is payable to the member or transferable to the new medical aid in the 6th month after resignation from the scheme.
3.2 Termination of membership
3.2.1 ResignationA member who, in terms of his/her conditions of employment is required to be a member of the scheme, may not terminate his/her membership while he/she remains an employee without the prior written consent of his/her employer. A member of the scheme who resigns from the service of his/ her employer shall, on the date of such termination, be eligible to continue as an individual member without re-applying or the imposition of any new restrictions that did not exist at the time of his/her resignation.
3.2.2 Voluntary termination of membershipA member, who is not required in terms of his/her conditions of employment to be a member, may terminate his/her membership of the scheme by giving three months written notice. All rights to benefits cease after the last day of membership.
3.2.3 Deceased membersThe dependants of a deceased member, who are registered with the scheme as his/her dependants at the time of such member’s death, shall be entitled to continued membership of the scheme without any new restrictions, limitations or waiting periods. Where a child dependant/s has been orphaned, the eldest child may be deemed to be the member, and any younger siblings, the child dependant/s.
4. Members’ portions
Members’ portions arise when health care service providers are refunded in full by the scheme, but the member still has to cover the cost of a co-payment applicable to the particular benefit or where levies are imposed. Members can refund the scheme by cheque/electronic payment, payroll deduction (if part of an employer group) or make use of the convenience of a debit order.
5. Benefits5.1 Choosing a benefit optionMembers are entitled to benefits during a financial year, as per the rules of the scheme and such benefits extend through the member to his/her registered dependants. A member must, on admission, elect to participate in any one of the available options, detailed in the rules of the scheme.
If you are a member of an employer group, your choice may be limited to the options agreed on between you and your employer. If you join as an individual, you may choose any of the various options according to your needs and affordability.
5.2 Option changesA member is entitled to change from one to another benefit option subject to the following conditions:• The change may be made only with effect from 1 January of any calendar year.• Application to change from one benefit option to another must be in writing and lodged with the scheme within
the period notified by the scheme.
5.3 Pro-rated benefitsIf members join the scheme later than 1 January during a specific year, pro rata annual benefits will apply until the end of the year. From 1 January the following year members will qualify for the full annual benefit.
6. How do I submit a claim?
Members are not required to complete a claim form. Simply sign all accounts and invoices and submit them directly to the scheme.
6.1 Electronic claimsMost service providers have the facility to submit claims electronically. These claims are then paid directly to the service provider, subject to the available limit, ensuring a very short processing turn-around-time. However it is the member’s responsibility to ensure that the claim/s reaches the medical aid within the four month time period from date of treatment and to check remittances for accuracy and validity of the claims submitted by the service providers.
6.2 Email/scanTo ensure that claims are promptly processed, please ensure that your name, membership number and contact number/s are on the claims and must be legible. Claims must be submitted within the four-month period from date of treatment.
Email: claims@universal.co.za
Post: Universal Healthcare Administrators (Pty) Ltd Private Bag X49 Rivonia, 2128
6.3 How does the claims process work?Claims are settled on a weekly basis for payment to the service providers or members. Members will receive a monthly detailed statement of claim’s transactions and of all payments made to the member and/or service providers. Kindly ensure that the scheme has your correct banking details to allow for electronic payment. It is ultimately the member’s responsibility to ensure that claims are submitted timeously for payment.
Specialist/sA referral must be obtained from your general practitioner for visits to specialists, with the exception of services provided by an ophthalmologist or gynaecologist, as well as a paediatrician for children under the age of two and urologist visit for males over 40. Failing to obtain a referral from your general practitioner will result in a 30% co-payment on the specialist account as well as on referrals to related services (such as pathology accounts, radiology accounts, physiotherapy etc.)
6.4 Over-the-Counter-Medicines (OTC)This medicine is dispensed by a registered pharmacist, who may prescribe medication for minor ailments that do not require a general practitioner consultation and will alleviate a consultation fee that your GP will normally invoice you. Please consult your benefit guide for the OTC rules and limits, and if applicable on your option. This benefit will include any homeopathic medication.
GLOSSARYCompCare Medical Scheme
AFB Annual Flexi BenefitAT Agreed tariffCDL Chronic Disease ListDSP Designated service providerOTC Over the counter medicinePB Per beneficiaryPMB Prescribed Minimum BenefitPMF Per Member FamilyPMSA Personal medical savings accountRP Reference PricingSPG Self-payment gapTL Threshold limitTTO To take out i.e. medicines taken out of hospital when discharged
This brochure is a summary of the benefits of CompCare Wellness Medical Scheme.All information relating to the 2019 CompCare Wellness Medical Scheme benefits and contributions are subject to formal approval by the Council for Medical Schemes. On joining the Scheme, all members will receive a detailed member brochure, as approved. The final registered Rules of the Scheme will apply.Administered by Universal Healthcare Administrators (Pty) Ltd
CONTACT DETAILSCompCare contact details:
Universal Place, 19 Tambach Road, Sunninghill Park, Sandton
PO Box 1411, Rivonia, 2128
Tel: 0861 222 777 | Fax: 0866 450 991E-mail: correspondence@universal.co.za
Website: www.compcare.co.za
Contact details for complaints escalated to the Council for Medical Schemes:
Tel: 0861 123 267E-mail: complaints@medicalschemes.com
Web: www.medicalschemes.com
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